Columbia  ©mtiersiftp     ^ 
inttieCitpofBetogorfe  *^ 

COLLEGE  OF  PHYSICIANS 
AND  SURGEONS 


jf  rom  tt)e  ILihxatp  of 
Br.  Cljrisitian  ^.  l^erter 

Bonatcb  bp 
iHrsf.  I^enrp  B.  Hafein 

1920 


DEATH  AND  SUDDEN  DEATH. 


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DEATH 


AND 


SUDDEN     DEATH 


P.    BROUARDEL, 


PROFESSOR  OF   MEDICAL  JURISPRUDENCE,    DEAN   OF   THE  FACULTY   OF    MEDICINE, 

PARIS,    MEMBER   OF   THE   INSTITUTE,    AND   OF   THE   ACADEMY   OF 

MEDICINE,    ETC. 


F.  LUCAS  BENHAM,  M.D.,  B.S.  (Lond.), 

MEMBER   OF   THE   ROYAL   COLLEGE   OF    PHYSICIANS   OF   LONDON. 


NEW    YORK: 
WILL.  lAM     WOOD     AND     CO 

1897. 


TRANSLATOR'S  PREFACE. 


A  WORK  by  Dr.  Brouardel,  whose  name  and  position  are 
so  well  known  in  this  country,  does  not  stand  in  need  of 
much  introduction  or  recommendation.  However,  a  few 
words  may  be  said  with  regard  to  the  motive  for  translation. 

In  the  first  place,  as  there  is  no  such  office  in  this  country 
as  Dr.  Brouardel  holds  as  Director  of  the  Morgue,  it  is  not 
an  easy  matter  over  here  to  obtain  the  amount  of  experience 
of  medico-legal  cases  that  he  possesses. 

The  book,  which  consists  of  part  of  a  course  of  lectures 
on  Forensic  Medicine,  treats  of  a  subject  which  is  hardly 
touched  on  in  English  medical  literature. 

The  substance  of  the  first  part — on  the  phenomena  ol 
death — is  certainly  dealt  with  more  or  less  fully  in  all  works 
and  lectures  on  medical  jurisprudence ;  but  this  somewhat 
dry  subject  is  here  presented  in  a  more  attractive  form  than 
is  customary,  and  there  are  several  novel  and  practical 
features  displayed  in  it. 

The  second  part  consists  of  what  may,  with  some  excuse, 
be  styled  clinical  lectures  on  the  various  forms  of  sudden 
death,  particularly  in  those   aspects  which  have  a  legal  or 


TRANSLATOR'S  PREFACE. 


practical  bearing.  This  subject  occupies  an  intermediate 
place  between  Forensic  and  Systematic  Medicine,  and  con- 
sequently is  usually  ignored  or  slurred  over  by  both.  In 
works  on  Forensic  Medicine  it  is  only  alluded  to  in  the 
most  general  way ;  and  in  text-books  on  medicine  it  is 
mentioned  only  briefly  and  incidentally.  Yet  the  subject 
is  one  of  vast  interest  and  importance,  and  there  is  dis- 
tinctly room  for  a  special  treatise  on  the  subject,  especially 
as  it  concerns  every  member  of  the  medical  profession. 

But  not  the  least  charm  of  the  book  is  its  attractive, 
lucid,  and  forcible  style,  which  recalls  in  many  ways 
Trousseau's  classical  clinical  lectures.  It  is  interesting 
as  well  as  instructive.  I  venture  to  hope  that  by  turning 
it  into  plain  English  the  spirit  of  the  original  may  not  be 
altogether  lost,  and  pains  have  been  taken  to  render  it  as 
accurate  as  possible. 

The  French  original  is  accompanied  by  a  very  lengthy 
appendix  of  illustrative  cases,  derived  from  many  sources, 
some  of  which  are  of  considerable  interest  and  value  ;  but 
the  records  are  not  all  equally  complete,  and  consequently 
they  vary  in  merit.  To  have  added  them  would  have 
swollen  the  book  to  a  very  great  and  inconvenient  bulk  ; 
and  it  has  been  deemed  expedient  to  omit  this  portion 
altogether.  There  are,  however,  numerous  striking  and 
vividly-described  cases  inserted  in  the  lectures,  which  serve 
to  illustrate  the  text,  and  will  deeply  impress  on  the  memory 
the  doctrines  and  facts  that  they  are  intended  to  exemplify. 

A  chapter  on  the  laws  of  France  dealing  with  the  disposal 
of  the  dead  has  been  retained.     Though  these,  of  course. 


TRANSLATOR'S  PREFACE. 


differ  from  our  own,  and  therefore  have  no  direct  practical 
bearing  for  us,  yet  it  may  be  of  use  to  many  to  learn  in  some 
detail  what  these  laws  are,  both  in  theory  and  practice,  that 
we  may  contrast  them  with  our  own  ;  as  it  has  been  urged 
by  authorities,  worthy  to  be  listened  to,  that  we  should  intro- 
duce them,  or  some  of  them,  on  this  side  of  the  Channel. 

F.  L.  B. 

Decembei-.  1896. 


AUTHOR'S  PREFACE. 


The  danger  of  premature  burial  and  the  unforeseen  nature 
of  sudden  death  have  occupied  pubHc  attention  at  all  times. 

I  thought  that  I  might  advantageously  exhibit  to  the 
students  of  the  Faculty  of  Medicine  the  actual  state  of 
these  questions,  by  utilizing  the  works  of  different  authors 
and  the  documents  which  the  numerous  medico-legal  autop- 
sies made  by  myself  and  my  fellow-workers,  MM.  Descoust, 
Vibert,  and  Socquet,  during  the  last  twenty  years  at  the 
Morgue,  have  furnished  to  us. 

I  have  attempted  to  show  that  the  uncertainties  which 
sometimes  arise  at  the  moment  of  death,  and  in  the  hours 
which  directly  follow,  may  be  removed  by  the  physician  ; 
that  his  intervention  is  often  necessary  to  establish  the 
reality  of  a  person's  death,  and  that  this  alone  can  remove 
every  apprehension  that  may  be  entertained  of  premature 
burial. 

Furthermore,  the  causes  of  sudden  death  are  but  ill 
understood.  They  are  very  numerous  ;  they  often  cause 
the  suggestion  of  crime  or  of  suicide  to  be  raised,  and  give 
rise  to  medico-legal  inquiries. 

No  medical  man  can  ignore  them  ;  the  expert  ought  to 
know  how  to  search  for  them,  and  how  to  avoid  the 
numerous  errors  that  it  is  easy  to  make.  Sudden  death  is 
one  of  the  most  complex  chapters  of  medical  jurisprudence. 

The  physician   is  well   acquainted  with  the  pathogeny  of 


xii  PREFACE. 

unforeseen  death  which  may  befall  patients  whose  diseases 
oblige  them  to  take  to  bed  or  to  enter  the  hospital.  These 
are  accidents  which  are  anticipated  or  dreaded — they  can- 
not take  anyone  by  surprise;  but  the  physician  knows  much 
less  of  the  causes  of  that  form  of  death  which  seizes  a  man 
unawares,  without  any  previous  warning,  even  while  he  is 
apparently  enjoying  perfect  health. 

I  have  shown  that,  in  spite  of  an  excellent  outward 
appearance,  sudden  death  is  the  termination  of  very 
different  diseases,  which  develop  secretly,  quite  unknown 
to  the  patient  and  those  around  him  :  such  are  certain 
affections  of  the  kidneys,  arterio-sclerosis,  diabetes,  etc. 

In  order  to  keep  this  volume  from  attaining  extravagant 
proportions,  I  have  been  obliged  to  limit  myself  to  a  brief 
summary  of  the  lesions  which  are  studied  in  treatises  of 
pathology  and  pathological  anatomy  ;  on  the  other  hand, 
I  have  laid  stress  on  the  circumstances  which  demand  the 
intervention  of  justice. 

These  lectures  were  intended  for  the  students  of  the 
Faculty.  Dr.  Reuss  considered  that  they  might  be  profit- 
ably consulted  by  doctors  also.  He  has  compiled  them 
with  very  great  care,  and  has  undertaken  the  material  part 
of  this  work.  If  the  reader  derive  any  profit  from  perusing 
these  pages,  he  will  be  indebted  for  it  to  my  excellent 
colleague.  Dr.  Reuss. 

P.  Brouardel. 

Paris, 
November  15.  1894. 


CONTENTS. 


PART  I. 


THE  SIGNS  OF  DEATH. 

LECTURE  PAGE 

I.  The  Moment  of  Death. — Apparent  Death  -  -  17 
Determination  of  the  moment  of  death. — At  what  moment 

does  life  cease  ?                  -                 -                 -  -  18 
Apparent  death     -                 -                 -                 -  -  25 
II.  The  Uncertainty  of  the  Signs  of  Death,  and  Prema- 
ture Burial    -               -               -               -  -  30 
Uncertainty  of  the  signs  of  death         -                 -  "  31 
Predisposition  to  apparent  death     -                 -  -  43 
Premature  burial  -                 -                 -                 -  -  48 
III.  The  Signs  of  Death              -               -               -  -  5° 
Insensibility          -                 -                 -                 -  -  50 
Motility                  -                 -                 -                 -  -  S3 
Respiration            -                 -                 -                 -  -  56 
Circulation             -                 -                 -                 -  -  56 
Cadaveric  suggillations         -                 -                 -  -  60 
Tempera.tuTe  pos^-fnorfe7/i    -                 -                -  -  62 
Parchment  patches. — Burns                 -                 -  -  65 
IV.  Rigor  Mortis           -               -               -               -  -  69 
V.  Putrefaction           -               -               -               -  -  79 
General  theory      -                 -                 -                 -  -  79 
Putrefaction  in  the  open  air                 ...  82 
Putrefaction  in  different  media            -                -  -  86 
Cadaveric  alkaloids               -                 -                 -  -  88 
Putrefaction  of  different  organs           -                 -  -  94 
Preservation  of  dead  bodies                 -                 -  .            -  97 
VI.  Cremation. — Mummification               -               .  .  103 
Cremation              .                 .                 _                 _ 
Embalming            .                  .                 .                 _ 
Mummification      -----  105 
VII.  Legislation.— Medico-Legal  Applications      -  -  iii 


103 
104 


CONTENTS 


PART  II. 

SUDDEN  DEATH. 

LECTURE  PAGE 

I.  Sudden  Death       -----  120 

II.  Sudden  Death  due  to  Lesions  of  the  Circulatory 

System  -  -  -  -  -  126 

I.  Lesions  of  the  heart  -  .  _  -  126 

A.  Cardiac  muscle  -  .  _  .  126 

1.  Fatty  overgrowth  of  the  heart      -  -  -  126 

2.  Fatty  degeneration  of  the  muscular   tissue  of  the 

heart  .  .  .  -  .  128 

3.  Fibroid  degeneration  of  the  heart  -  -  128 

4.  Lesions  of  the  coronary  arteries  -  -  -  129 

5.  Rupture  of  the  heart    -  -  -  -  129 

B.  Pericardium     -  -  -  -  -  130 

C.  Aortic  incompetence       ....  1-52 

D.  Mitral  and  tricuspid  incompetence  -  -  133 

E.  Endocarditis   ...  -  -  136 

F.  Angina  pectoris  .  .  _  .  138 

G.  Neoplasms  of  the  heart  -  -  -  -  139 

II.  Lesions  of  the  arteries        _  .  .  .  140 

A.  Congenital  lesions  .  .  -  .  140 

B.  Arterio-sclerosis  .  .  _  .  142 

C.  Aneurysms       .  .  -  _  -  144 

III.  Lesions  of  the  veins  ....  145 

A.  Rupture  of  veins  ....  145 

B.  Thrombosis  and  embolism  -  -  -  145 

C.  Air  in  the  veins  -  -  -  -  150 

IV.  Lesions  of  the  capillaries  -  -  -  -  I53 

A.  Miliary  aneurysms  -  -  -  -  I53 

B.  Meningeal  heem.orrhages  -  -  -  156 

C.  Capillary  embolisms       _  -  .  -  157 

D.  Local  disturbances  of  the  circulation  -  -  158 

III.  Sudden  Death  due  to  Lesions  of  the  Cerebro-Spinal 

System  and  the  Major  Neuroses  -  -  i6r 

I.  Meningitis  .  .  -  -  .  161 

II.  Abscess  of  the  brain  .  -  .  .  16^ 

III.  Cerebral  tumours-  ....  165 

IV.  Lesions  of  the  spinal  cord  -                 -                 -                 -  167 
V.  Epilepsy                -                 -     ■             -                 -           .      -  168 

VI.  Hysteria  .  _  .  .  .  170 

VII.  Inhibition.— Slight  injuries  -  -  -  171 


CONTENTS. 


LECTURE  PAGE 

IV.  Sudden  Death  due  to  Lesions  of  the  Respiratory 

System               -               -               -               -               -  i77 

I.  Lesions  of  the  larynx,  trachea,  and  bronchi       -                 -  177 

A.  Lesions  of  the  larynx      -                 -                 -                 -  177 

B.  Lesions  of  the  trachea    -                 -                 -                 -  178 

C.  Lesions  of  the  thyroid  body            -                 -                 -  I79 

D.  Lesions  of  the  mediastinurri           -                 -                 -  179 

II.  Lesions  of  the  lungs            .                 .                 .                 .  181 

A.  Pulmonary  congestion    -                 -                 -                 -  181 

B.  Pneumonia       -----  183 

C.  Capillary  bronchitis         -                  -                 -                 -  184 

D.  Pulmonary  phthisis         -                 .                  -                 -  187 

E.  Cancer  of  the  lung          ...                 -  188 

F.  Emphysema  of  the  lungs                -                 _                 .  189 

G.  Pleurisy            -                 -                 -                 -                 -  189 
H.  Rupture  of  the  diaphragm              -                -                 -  193 

V.  Modifications  of  Vascular  Tension  :  Their  Action 
AS   Auxiliary   Causes,  or  as   Efficient    Causes 

(when  in  Excess)           -               -               -               -  194 

I.  Auxiliary  causes  :  effort,  cold,  heat    -                 -                 -  194 

II.  Efficient  causes  :  cold,  heat                 ...  jg5 

A.  Heat                 -                 -                 -                 -                 -  196 

B.  Cold                  -                 -                 -                 -                 -  201 

VL  Sudden  Death  due  to   Lesions    of  the    Digestive 

System              -               .               .               .               .  206 

I.  Lesions  of  the  pharynx        -                 -                 -                 -  206 

II.  Lesions  of  the  oesophagus    -                 -                 -                 -  208 

HI.  Lesions  of  the  stomach        .                 .                 -                 -  209 

IV.  Lesions  of  the  intestines      -                 -                 -                 -  215 

V.  Lesions  of  the  liver               .                 .                 _                 -  220 

VI.  Lesions  of  the  spleen           .                 _                 .                 .  223 

VII.  Lesions  of  the  pancreas       -                 -                 -                 .  225 

VIII.  Lesions  of  the  suprarenal  capsules     -                 -                 -  225 

VI L  Sudden  Death   caused    by  Lesions  of  the   Female 

Genital  Organs            ....  226 

A.  Vaginal  examination       -                 .                 -                 .  226 

B.  Extra-uterine  gestation  -                 -                 -                 -  228 

C.  Retro-uterine  hematocele               -                 -                 -  229 

D.  Rupture  of  the  uterus     -                 -                 -                 -  230 

E.  Vulvo-vaginal  varices     -                 -                 -                 .  230 

F.  S>ncope           -----  231 

G.  Chloroform      -----  232 


CONTENTS. 


LECTURE 

VOL  Sudden  Death  in  Fevers  - 

IX.  Sudden  Death  due  to  H/emophilia 
X.  Sudden  Death  in  Diabetes 

XL  Sudden  Death  due  to  the  Kidneys 

A.  Uraemia — auto-intoxication 

B.  Gout 

XII.  Sudden  Death  in  Alcoholism 

A.  Drunkenness  - 

B.  Delirium  tremens 

C.  Chronic  alcoholism 

D.  Medico-legal  intervention 

XIII.  Sudden  Death  in  Children 

A.  Syncope 

B.  Convulsions     - 

C.  Asphyxia 

D.  Pulmonary  congestion  - 

E.  Intestinal  disorders 


234 

236 

239 

244 
244 
252 

255 
255 
257 

257 
258 

263 
263 
264 
266 
268 
270 


DEATH   AND  SUDDEN  DEATH. 

PART  I. 
THE  SIGNS  OF  DEATH. 

LECTURE  I. 

THE  MOMENT  OF  DEATH.— APPARENT  DEATH. 

Gentlemen, — To  the  medical  jurist  the  study  of  the  causes 
of  death,  of  the  phenomena  which  precede  the  examination 
of  the  corpse,  is  of  great  importance ;  in  more  than  half 
of  the  medico-legal  examinations  that  you  will  be  called 
upon  to  make,  whether  the  question  raised  is  one  of  suicide, 
murder,  sudden  death,  or  survivorship,  it  is  with  the  study  of 
the  dead  body  that  you  will  have  to  begin. 

Activity  does  not  entirely  cease  at  the  instant  of  death. 
Vital  phenomena  are  replaced  by  cadaveric  phenomena  :  it 
is  requisite  that  you  should  become  familiar  with  these  last, 
for  inexperienced  medical  men  have  ascribed  to  poisoning 
lesions  which  have  been  really  produced  after  death  by  the 
normal  processes  of  decomposition. 

In  order  that  you  may  be  able  to  pronounce  an  opinion  as 
to  the  cause,  I  am  going  to  investigate  with  you  the  possi- 
bility of  determining  the  exact  instant  of  death.  I  shall 
then  study  apparent  death  (which  will  lead  me  to  speak  to 
you  of  premature  interment),  the  real  signs  of  death  and  the 

2 


THE  SIGNS  OF  DEATH. 


legal  questions  which  have  to  do  with  the  proof  of  death. 
I  shall  finish  this  course  with  an  inquiry  into  the  causes  of 
sudden  death. 

DETERMINATION  OF  THE  MOMENT  OF  DEATH.— AT 
WHAT  MOMENT  DOES  LIFE  CEASE? 

That  is  a  question  which  looks  very  easy  to  answer.  There 
is  not  one  of  us,  Gentlemen,  who  has  not  been  present,  at 
least  once,  at  this  final  scene  of  every  human  existence,  who 
has  not  seen  a  dying  man  draw  his  last  breath.  The  stoppage 
of  respiration,  or,  to  use  the  customary  expression,  the  last 
breath,  is,  as  a  matter  of  fact,  considered  by  the  public  as 
the  unequivocal  sign  of  the  disappearance  of  life.  This  is  a 
grave  error,  Gentlemen,  for  many  persons  who  no  longer 
breathe  have  been  recalled  to  life  by  means  of  care  and  skill. 
The  moment  of  death  cannot  therefore  be  assumed  to  be 
identical  with  cessation  of  respiration. 

It  has  been  thought  possible  to  find  a  more  exact  criterion 
in  the  pulsation  of  the  heart.  The  coj'  ultimum  moriens  has 
been  regarded  as  the  rule  since  the  time  of  Galen  ;  physio- 
logists have  agreed  upon  it.  In  their  laboratories  stoppage 
of  the  heart  is  looked  on  as  the  end  of  life  :  as  soon  as  the 
heart  of  an  animal  that  is  being  experimented  upon  ceases 
to  beat,  physiologists  admit  that  the  animal  is  dead. 

Can  we  accept  this  criterion  in  forensic  medicine  ?  I  do 
not  think  so.  In  certain  medico-legal  cases,  the  value  of 
the  sign  may  be  disputed  ;  the  judge  may  ask  you  to  say  at 
what  precise  moment  death  took  place,  and  that  for  several 
reasons.     Here  are  some  examples  : 

A  man  is  murdered  :  several  individuals  have  been  seen 
to  strike  him  ;  these  individuals  are  arrested  ;  the  judge  may 
ask,  and  will  ask,  the  expert  to  determine  which  of  the  blows 
inflicted  has  actually  been  the  fatal  one.  Need  I  tell  3^ou  of 
the  importance  of  this  decision  from  the  point  of  view  of  the 
responsibility  of  each  of  the  assailants  ? 

In  a  railway  accident  an  entire  family  is  killed  and  dis- 
appears in  the  course  of  a  few  seconds  ;  suppose  that  the 
husband  has  his  head  separated  from  the  trunk,  and  that 
the  body  of  the  wife  does  not  show  the  mark  of  any  injury. 


THE  MOMENT  OF  DEATH.  19 

Which  of  these  two  expired  first  ?  This  question  of 
survivorship,  which  will  be  put  to  you  without  fail,  is  of 
extreme  importance  from  the  point  of  view  of  inheritance. 

When  a  case  of  murder  has  to  be  dealt  with,  the  investiga- 
tion is  usually  entrusted  to  a  single  medico-legal  expert. 
When  questions  of  survivorship  and  inheritance  are  raised, 
there  are  at  least  three  of  them  ;  there  is  often  an  expert  to 
give  evidence  on  the  opposite  side  ;  sometimes  the  conclu- 
sions of  the  second  expert  are  at  variance  with  those  of  the 
first.  The  Court  of  Appeal  sometimes  orders  a  report  by  a 
third  expert.  This  single  example  will  suffice  to  show  you 
what  difficulties  you  will  have  to  combat. 

We  cannot  admit,  in  forensic  medicine,  that  stoppage  of 
the  heart  is  a  certain  sign  of  death. 

Recall  to  your  mind  the  crime  of  the  Rue  Montaigne,  the 
case  of  Pranzini,  which  has  been  included  among  the  causes 
celebres  of  our  time.*  Pranzini  killed  Marie  Regnault,  her 
maid,  and  her  little  girl,  who  may  have  been  the  child  of 
either  of  these  women,  but  who  had  at  all  events  been 
adopted  by  the  former.  Marie  Regnault  had  her  throat  cut 
and  the  carotids  were  severed,  but  the  vertebral  column  was 
intact ;  she  had  fallen  at  the  foot  of  the  bed,  but  her  hand 
retained  hold  of  the  bell-rope  ;  she  had  doubtless  been 
attacked  while  in  bed.  The  maid  had  heard  her  mistress's 
bell  ring,  and  had  had  time  to  put  on  a  petticoat  ;  then  she 
had  been  struck  in  her  turn  :  she  fell  with  her  neck  deeply 
cut,  the  vertebral  column  was  opened  behind,  and  the 
posterior  columns  of  the  spinal  cord  were  divided.  Pranzini 
lastly  killed  the  child  in  her  bed,  no  doubt  because  she  cried 
out.  The  last  victim  was  literally  decapitated,  the  vertebral 
column  was  completely  divided,  and  the  head  was  only 
united  to  the  trunk  by  a  strip  of  skin  along  the  front  of  the 
neck. 

The  magistrate  directed  me  to  proceed  with  the  autopsy 
of  the  bodies,  and  to  determine  the  circumstances  of  the 
crime.  The  question  of  survivorship  was  necessarily  raised  ; 
its  elucidation  was    specially  interesting,  as  the   rights    of 

*  Brouardel,  'Affaire  Pranzini  :  Triple  Assassinat — Relation  medico- 
legale'  {Ann.  d Hyg.,  1887,  tome  xviii.,  p.  305). 


THE  SIGNS  OF  DEATH. 


inheritance  and  succession  depended  upon  its  solution. 
Evidently  Marie  Regnault  was  the  first  to  be  struck,  then 
the  maid,  and  lastly  the  child ;  but  which  of  the  three 
victims  was  the  last  to  die  ?  What  criterion  could  be  relied 
upon  to  fix  the  exact  moment  of  death  in  the  case  of  each  : 
Marie  Regnault,  whose  carotids  were  opened,  died  of 
haemorrhage ;  the  maid  had  a  lesion  of  the  spinal  cord  ;  the 
little  girl  was  beheaded. 

Some  time  before  this,  Drs.  Regnard  and  Paul  Loye  had 
been  present  at  an  execution  at  Troyes ;  they  even  rode  in 
the  van  which  carried  the  body  from  the  scaffold.  One  hour 
after  the  execution  the  heart  still  beat  ;  yet  this  man's 
existence  was  over  ;  he  had  lost  his  personality,  and  yet  his 
heart  v/as  beating  !  Well,  to  us  and  to  everyone  a  decapi- 
tated person  is  a  dead  man,  although  his  heart  does  continue 
to  contract  ! 

My  experiments  in  conjunction  with  Dr.  Paul  Loye*  had 
shown  me  that,  when  a  dog  is  decapitated,  movements  of  the 
heart  persist  for  fifteen,  twenty,  or  twenty-five  minutes  after- 
wards ;  but  they  had  also  demonstrated  that  it  was  quite 
the  same  when  the  animal  died  of  haemorrhage. 

So  when  this  question  of  survivorship  was  put  to  me  in 
the  Pranzini  case,  I  sought  the  opinion  of  our  most  eminent 
physiologists  :  Brown-Sequard,  Vulpian,  MM.  Franck  and 
Marey.  Gentlemen,  they  declared  themselves  quite  unable 
to  solve  the  problem  ;  moreover,  that  was  my  own  view,  and 
I  gave  as  my  conclusion  that  I  could  not  say  which  of  the 
three  victims  had  died  the  last. 

Allow  me  in  connexion  with  this  matter  to  give  you  a 
piece  of  advice.  When  you  have  not  a  scientific  demonstra- 
tion of  the  facts,  always  say,  in  giving  your  opinion,  that  you 
do  not  know.  Not  only  will  you  be  speaking  the  truth,  but 
it  is  much  better  to  say  at  the  preHminary  examination,  '  I  do 
not  know,'  than  to  be  forced  at  the  trial  to  say,  '  I  did  not 
know.'  In  these  matters  the  law  allows  the  magistrate  to 
apply  simply  the  Articles  of  the  Civil  Code,  which  enable  him 
to  settle  the  difficulty.     That  is,  you  will  say,  purely  con- 

*  P.  Brouardel  and  P.  Loye,  '  Recherches  exp^rimentales  sur  la  Mort 
par  Submersion  brusque'  (Arc/nv.  de  Physiologie,  ic 


THE  MOMENT  OF  DEATH.  21 

ventional ;  I  admit  that  it  is,  but  it  is  a  legal  convention, 
and  the  arrest  of  the  heart  as  a  sign  of  death  is  also  a  con- 
vention, but  one  belonging  to  physiology  and  disputable. 
I    am    anxious    to    narrate    another    instance    to    you. 

M.  R and  his  wife  went  for  a  row  in  a  boat.     The  boat 

upset ;  the  rowers  saw  M.  R rise  several  times^  strug- 
gling on  the  surface  of  the  water ;  no  one  saw  Mme.  R 

again.  They  had  each  left  a  will  bequeathing  their  respec- 
tive fortunes  to  the  survivor.  The  experts  at  Dijon  (the 
accident  happened  in  the  Cote-d'Or),  admitted  in  their  con- 
clusions that  M.  R had  died  last,  because  he  was  seen 

several  times  on  the  surface.  On  the  other  hand,  the 
experts  of  Marseilles,  where  one  of  the  families  lived,  pro- 
nounced the  opinion  that  an  individual  who  rises  to  the 
surface  will  be  drowned  more  surely  and  more  rapidly  than 
another  who  sinks  to  the  bottom  and  remains  there  in  the 

state  of  syncope  ;   according  to  them,  Mme.    R must 

have  survived  her  husband.  A  third  expert  opinion  was 
ordered,  which  was  entrusted  to  me  ;  I  declared  that  I  could 
give  no  reply  to  the  question  which  was  put  to  me,  because 
I  did  not  know  absolutely  which  of  the  two  had  survived  the 
other.  This  view  was  finally  accepted,  and  the  two  families 
shared  the  fortunes  of  both  deceased.  They  might  have 
saved  themselves  the  expense  if  they  had  only  begun  where 
they  left  off. 

At  present,  then,  gentlemen,  we  have  no  absolute  criterion 
at  all  to  determine  the  precise  moment  of  death,  even  when 
we  believe  that  the  concomitant  circumstances  afford  strong 
grounds  of  probability.  These  proofs  are  no  more  than 
merely  probable. 

Finally,  sensitiveness  varies  very  much,  according  to  age  and 
sex  and  the  states  of  surprise  and  sudden  awaking  from  sleep. 
As  a  result  of  strong  emotions,  certain  persons  may  be 
seized  with  syncope,  others  may  pass  into  the  contrary  state 
of  excitement.  Between  these  two  extremes  there  are  com- 
plex cases  in  which  the  character  of  the  emotion  undergoes 
great  changes  or  variation. 

Besides  this,  it  is  known  in  medical  jurisprudence,  though 
it  has  only  been  learnt  recently,  that  blows,   even  though 


THE  SIGNS  OF  DEATH. 


slight,  which  fall  on  certain  parts  of  the  body,  may  cause 
instantaneous  death.  I  will  relate  to  you,  in  illustration  of 
this,  a  ver}^  typical  example.  A  priest,  whose  conduct  was 
not  as  immaculate  as  it  might  be,  was  obliged  to  remove 
his  mistress  from  his  vicarage.  '  The  day  had  passed  very 
sadly,'  said  Abbe  Delacollonge.  '  Everything  was  got  ready 
for  her  departure  ;  the  sorrow  had  broken  my  heart,  and  I 
said  to  her :  "  We  should  be  happier  if  we  were  dead." 
"Yes,"  said  she,  "if  we  could  die  together."  I  then  said 
to  her  jokingly,  for  I  could  find  no  other  way  of  expressing 
myself  at  the  moment  :  "  Could  you  bear  me  to  cause  you 
much  pain  ?"  "  Tr}^"  she  replied.  "We  were  both  standing 
up.  I  took  hold  of  her  neck  ;  it  was  intended  as  a  harm- 
less piece  of  fun  on  my  part,  and  she  showed  by  a  smile 
that  she  regarded  it  as  such.  All  at  once  she  made  a  sign 
of  pain  and  shook  her  hands,  but  without  uttering  any  cry. 
I  relaxed  the  pressure,  and  she  fell  down.  I  picked  her  up, 
but  she  was  dead.' 

The  medico-legal  experts  neither  accepted  nor  rejected 
this  hypothesis  completely  ;  they  spoke  of  asphyxia,  syncope, 
etc. 

During  the  hearing  of  the  case,*  an  ex-officer,  M.  Boure, 
made  the  following  deposition  :  '  We  were  at  Tarbes,  sta}'- 
ing  in  garrison.  Among  our  number  were  Captains  Lalande 
and  Surugues.  In  a  moment  of  friendly  mirth.  Captain 
Lalande  seized  Captain  Surugues  b}'  the  neck  b}^  way  of  a 
joke.  "  Now,  old  fellow,"  said  he  to  him,  "  I  am  going  to 
put  you  out  of  the  way  !"  (This  was  only  said  playfully.) 
Captain  Surugues,  however,  staggered  and  fell  in  a  state 
of  unconsciousness.  Owing  to  the  skilful  attention  we 
bestowed  upon  him,  he  soon  returned  to  life,'  etc. 

The  parts  of  the  human  body,  contusion  of  which  may 
induce  sudden  death,  are  the  laryngeal  and  epigastric 
regions,  the  genital  organs  and  the  nostrils ;  even  irritation 
of  these  parts  sometimes  suffices  to  provoke  a  catastrophe. 
During  the  reign  of  Louis  Philippe,  a  Danish  physician 
professed  to  cure,  or  at  least  to  check,  attacks  of  asthma 
by  cauterizing  the  pharynx  with  ammonia.  He  had  acquired 
*  Assize  Court  of  the  Cote-d'Or,  March  i,  1836. 


THE  MOMENT  OF  DEATH. 


23 


a  considerable  reputation,  and  the  King's  sister  wished  to 
submit  herself  to  his  treatment.  It  happened,  however, 
that  a  maid  of  honour,  who  was  asthmatic  herself,  died 
suddenly  at  the  moment  the  physician  touched  her  pharynx 
with  the  ammonia.  From  that  time  there  was  no  more 
talk  of  the  Danish  physician  or  of  his  wonderful  cures. 

It  is  consequently  necessary  in  forensic  medicine  that  we 
should  be  aware  that  violence,  or  even  irritation,  of  but  slight 
apparent  intensity,  applied  to  certain  regions  of  the  body, 
may  determine  sudden  deaths  even  vvithout  our  being  able 
to  discover  any  visible  traces  of  contusion,  such  as  ecch\-- 
rnoses.  The  fact  is,  that  when  a  blow  has  ruptured  the 
capillaries,  provided  that  the  heart  continues  to  beat,  the 
blood-stream  will  continue  to  reach  the  spot,  and  there  will 
be  an  extravasation  ;  but  if,  on  the  contrary,  the  heart's 
action  has  ceased,  there  is  no  m.ore  onward  movement  of 
the  circulation  ;  the  blood  may  escape  so  as  to  form  a  small 
thin  patch,  but  there  is  no  effusion,  no  ecchymosis. 

What  is  the  explanation  of  these  cases  of  sudden  death  ? 
It  used  to  be  said  that  the  individual  died  of  svncope. 
M.  Brown-Sequard,  who  has  thoroughly  studied  all  these 
matters,  says  '  death  is  due  to  inhibition.'  What  is  inhibi- 
tion, gentlemen  ?  It  is  a  term  which  you  hear  repeated 
again  and  again  in  scientific  discussions  :  perhaps  you  do 
not  thoroughly  understand  its  meaning  and  importance. 

Your  physiological  studies  have  taught  you  that  nearlv  all 
vital  acts  are  reflex  nervous  actions,  A  peripheral  excita- 
tion propagated  through  the  system  will  evoke  reflex  action 
which  will  give  rise  to  movements.  Sneezing  is  the  tvpe 
of  reflex  movements  :  irritation  of  a  very  small  point  of  the 
nasal  mucous  membrane  is  transmitted  to  the  corresponding 
reflex  centre  ;  this  one  transmits  to  other  centres  the  excita- 
tion it  has  just  received  ;  immediately,  a  certain  number  of 
organs  endowed  with  special  functions  react,  and  vou  have 
then  that  inspiratory  and  expiratory  perturbation,  those 
movements  of  the  face,  shoulders,  arms  and  chest,  that  flow 
of  tears  and  of  nasal  mucus — in  one  word,  all  that  group  of 
phenomena  which  constitutes  sneezing. 

Well,  gentlemen,  suppose  that  under  the  influence   of  a 


THE  SIGNS  OF  DEATH. 


violent  physical  or  moral  excitation,  instead  of  reflex  move- 
ments taking  place,  these  are  arrested;  suppose  that  the 
excited  centre  paralyses  the  action  of  other  centres  which 
are  already  in  activity  ;  that  paralysis  is  inhibiiion.  When 
the  pneumogastric  nerve  is  excited,  the  heart  stops ;  when 
the  cervico-dorsal  region  of  the  spinal  cord  is  excited,  the 
activity  of  the  stomach  ceases  ;  the  irritation  of  the  bulb 
caused  by  the  pneumogastric  inhibits  the  heart ;  excitation 
of  a  certain  part  of  the  spinal  cord  inhibits  the  stomach. 

Reflex  centres  can  therefore  act  upon  one  another  either 
so  as  to  excite  them  or  so  as  to  inhibit  them  ;  so  that  we 
are  now  in  a  position  to  define  inhibition  as  the  arrest  of 
a  function  provoked  by  an  excitation  of  a  distant  part  of 
the  nervous  system.  If  this  excitation  is  violent  enough, 
the  functions  may  cease,  never  to  return,  and  if  these 
functions  are  necessary  to  life,  death  will  of  course  be  the 
consequence  of  their  cessation. 

M.  Brown-Sequard  assigns  to  death  by  inhibition  three 
pecuhar  characteristics  :  (i)  It  takes  place  without  a 
struggle,  without  convulsions — in  fact,  as  calmly  as  possible  ; 
(2)  the  venous  blood  remains  red  for  a  very  long  time  with- 
out turning  black  ;  (3)  finally,  the  temperature  of  the  corpse 
falls  very  rapidly. 

The  medico-legal  expert,  when  called  upon  to  make  an 
examination  of  a  body,  arrives  too  late  to  witness  all  these 
phenomena  ;  therefore  I  do  not  want  to  discuss  them 
before  you  to-day;  I  shall  only  say  this,  that  you  ought 
always  to  ask  yourselves  whether  an  individual  in  the 
state  of  apparent  death  might  not  return  to  hfe,  notwith- 
standing the  cessation  of  the  movements  of  the  heart  and 
of  respiration  ;  whether  the  suspension  of  life  is  temporary 
or  absolute ;  and  I  think  that  it  will  be  possible  in  a 
great  many  cases  to  save  the  individual  and  restore  him 
to  life,  for  the  simple  reason  that,  as  a  result  of  inhibition, 
the  blood  retains  its  vital  properties  for  a  fairly  long  time. 


APPARENT  DEATH. 


APPARENT  DEATH. 

Other  difficulties  also  contribute  to  justify  our  reserve. 

When  an  individual  dies,  there  is  no  interruption  in  the 
chemical  changes  which  go  on  in  his  body.  This  con- 
tinuity of  changes  constitutes  the  chief  difference  between 
inorganic  substances  on  the  one  hand  and  animals  and 
vegetables  on  the  other.  There  is  in  these  latter  a  con- 
tinual exchange  of  used  -  up  matters  and  assimilable 
matters  ;  inorganic  bodies  are  in  a  state  of  chemical  repose. 

These  phenomena  are  continued  energetically  after  death, 
and  even,  in  certain  infective  diseases  such  as  small-pox  or 
rabies,  with  such  a  degree  of  energy  that  the  temperature 
of  the  body  is  raised  from  2°  to  4^°  F.,  although  the  move- 
ments of  the  heart  and  respiration  are  arrested.  These 
are  chemical  changes  of  a  very  active  kind,  but  they  obey 
different  laws  from  those  which  prevail  during  life. 

This  is  not  all :  there  is  also  the  independence  of  the  functions 
and  of  the  tissues.  You  know  that  in  the  lower  animals  inde- 
pendence of  the  functions  is  carried  to  an  extreme  ;  you 
have  seen  that  the  heart  may  continue  to  beat  in  a  man, 
even  after  decapitation.  Claude  Bernard  and  Longet  agree 
in  saying  that  the  liver  of  a  dead  animal,  placed  on  a  table, 
retains  its  glycogenic  function  for  some  hours.  M.  Bouchard 
and  I  separately  performed  identical  experiments  on  the 
production  of  urea,  and  obtained  the  same  result.  Need  I 
remind  you  that  muscular  excitability  persists  for  a  certain 
time  in  an  amputated  limb  ?  The  unity  of  the  living  being 
is  therefore  only  apparent,  and  we  are  therefore  justified  in 
saying  that  an  individual  does  not  die  in  every  part  in  a 
single  minute. 

Another  important  point  is  the  suspension  of  the  organic 
functions  during  life.  In  hibernating  animals  the  functions 
of  respiration  and  circulation  are  reduced  to  the  minimum 
during  their  winter  sleep.  Submit  them  while  in  this  state 
to  a  reduction  of  temperature  of  g°  to  1^°  F.  ;  the  vital 
phenomena,  already  nearly  imperceptible,  are  absolutely 
arrested,  so  that,  if  you  were  to  cut  one  of  the  animal's  paws, 


26  THE  SIGNS  OF  DEATH. 

you  would  have  a  little  oozing  of  blood,  but  not  a  stream  ; 
tap  the  heart  with  the  end  of  your  scalpel,  and  you  will  not 
induce  a  contraction,  and  it  will  be  equally  impossible  to 
arouse  muscular  contractility. 

Take  these  animals  now ;  warm  them  gradually  for  an 
hour  up  to  an  increased  temperature  of  i8°  F.,  and  they  will 
resume  their  vital  functions  ;  they  were  therefore  in  a  state 
of  apparent  death.  Is  there  not  room  for  reflexion,  when 
we  see  how  closely  these  phenomena  apply  to  the  case  of 
human  beings? 

Captain  Ross,  in  his  expedition  to  the  North  Pole,  took 
with  him  a  box  containing  silkworms  ;  he  exposed  them  on 
the  bridge  of  his  ship  to  a  temperature  of  —  43'6°  F,  and 
froze  them  ;  these  silkworms,  while  in  this  condition,  re- 
sembled little  bits  of  dry  wood,  and  could  be  broken  into 
several  pieces  with  the  greatest  ease  ;  Captain  Ross  had 
these  silkworms  warmed  again,  and  the  greater  number 
revived ;  he  repeated  the  experiment  three  times,  and  after 
the  third  time  of  freezing  the  last  survivors  still  produced 
moths,  the  appearance  of  which  he  has  described,  but  they 
were  imperfect ;  he  had  formed  monsters. 

It  is  possible,  then,  in  certain  animals  to  suspend  life  and 
restore  it  ;  those  which  enjoy  this  faculty  have  been  called 
'resuscitating  animals';  certain  vegetables  possess  similar 
properties,  such  as  the  grains  of  wheat  found  in  the  coffins 
of  Egyptian  mummies,  which,  when  sown  after  thousands  of 
years,  have  germinated  and  fructified.* 

Is  there  any  condition  then,  Gentlemen,  in  the  range  of 
our  pathology,  in  which  we,  as  human  beings,  resemble  these 
hibernating  animals  ?  Yes,  there  are  certain — I  do  not  say 
all  —  hysterical  states  which  present  similar  phenomena. 
There  are  many  malingerers  among  hysterical  subjects; 
but  it  is  no  less  true  that  in  certain  patients  of  this  class 
nutrition  and  excretion  are  reduced  to  the  minimum.  They 
maintain  their  nutrition  on  two  or  three  figs  per  diem,  and 
excrete  less  than  half  an  ounce  of  urine  and  scarcely  any  faeces 

*  M.  Casimir  de  Candolle  read  an  interesting  paper  on  '  Latent  Life 
in  Seeds '  at  the  meeting  of  the  British  Association  for  the  Advancement 
of  Science,  1896.— TRANSLATOR. 


APPARENT  DEATH.  27 

at  all.  The  observations  of  Empereur  demonstrated  also 
that  these  hysterical  patients  did  not  excrete  one-fifth  part 
of  the  normal  amount  of  carbonic  acid.  The  conclusion 
may  be  drawn  from  these  facts  that  there  exists  a  group  of 
women  in  whom  the  nutritive  changes  are  at  the  minimum ; 
their  life  is  almost  latent. 

If  this  condition  is  pushed  to  a  farther  degree,  these 
women  may  remain  for  a  time,  which  we  can  measure  in 
cases  of  lethargy  and  catalepsy,  in  a  state  of  apparent  death  ; 
their  life  is  entirely  latent. 

We  may,  without  being  hysterical,  be  able  to  reduce  or 
arrest  the  movement  of  circulation.  Bonders  and  M.  Chau- 
veau  have  succeeded  in  doing  so.  M.  Chauveau,  whose 
stature  you  know,  managed,  after  preparing  himself  by  taking 
a  deep  inspiration  which  caused  4,850  to  5,800  cubic  inches 
of  air  to  enter  his  chest,  to  stop  his  heart  for  a  whole  minute. 
It  was  not  merely  by  auscultation  that  this  could  be  proved  : 
the  sphygmograph  applied  to  the  radial  artery  gave  a 
perfectly  straight  line  corresponding  to  this  space  of  time. 
Some  persons,  therefore,  can  arrest  their  circulation  for  an 
instant. 

An  Englishman,  Colonel  Townshend,  asserted  that  he 
could  arrest  the  movements  of  his  heart  for  half  an  hour. 
Cheyne  relates  that  this  Colonel,  who  had  been  ill  a  long 
while,  took  it  into  his  head  one  day  to  send  for  Drs.  Cheyne 
and  Baynard,  who  were  in  attendance  upon  him,  and  for 
Mr.  Skrine,  his  apothecary,  to  beg  them  to  witness  a  singular 
experiment  which  he  v/as  anxious  to  repeat  in  their 
presence  ;  it  was  to  cause  himself  to  die  and  to  return  to 
life.  The  patient  lay  on  his  back ;  Dr.  Cheyne  kept  his 
finger  on  the  pulse.  Dr.  Baynard  placed  his  hand  over  the 
heart,  Mr.  Skrine  held  a  mirror  before  the  mouth.  Shortly 
after,  no  arterial  pulsation  or  cardiac  movement  could  be 
felt,  and  the  breath  did  not  dim  the  glass.  This  spectacle 
having  lasted  for  more  than  half  an  hour,  the  spectators  were 
about  to  withdraw,  persuaded  that  the  patient  had  pushed 
his  experiment  too  far,  when  they  perceived  some  movement, 
then  they  felt  the  beats  of  the  pulse  and  of  the  heart  return 
by   degrees,   and   respiration    recommenced ;    in   time   the 


THE  SIGNS  OF  DEATH. 


patient  began  to  speak,  and  left  the  spectators  equally- 
astonished  at  his  death  and  resurrection.  When  they  had 
gone  awa}',  the  Colonel  sent  for  his  attorney,  added  a  codicil 
to  his  will,  and  expired  peaceably  eight  hours  after  the 
experiment.* 

Certain  special  predispositions  and  certain  peculiar  cir- 
cumstances must  also  be  taken  into  account  :  blows  in  the 
epigastrium  give  rise  to  an  inhibition  ;  this  is  especially  true 
while  the  process  of  digestion  is  going  on.  Experiments  on 
dogs  are  conclusive  as  to  this.  A  Polish  physiologist  has 
made  some  very  curious  observations  on  frogs  by  aid  of 
Marey's  recording  apparatus.  He  used  a  little  hammer, 
weighing  45  to  60  grains,  with  which  he  struck  the  frog's 
stomach ;  when  the  animal  had  been  eating,  the  pulse 
became  slow  and  the  apparatus  registered  scarcely  two  or 
three  beats  per  minute  :  when  the  animal  was  fasting,  the 
pulsations  underwent  no  change. 

Finally,  1  ought  not  to  leave  you  ignorant  of  certain 
idiosyncrasies,  which  I  entitle  unfortunate  ;  such  is  the  case 
of  certain  women  who  may  die  suddenl}^  after  the  introduc- 
tion of  a  uterine  sound. 

When  we  have  studied  the  phenomena  of  death,  and  when 
I  come  to  speak  to  you  of  putrefaction,  you  will  see  that  the 
decomposition  of  a  body  does  not  resemble  in  any  way  that 
of  any  other  substance.  When  an  individual  dies  from  an 
accident  and  the  body  is  entire,  putrefaction  goes  on  rapidly, 
and  gaseous  infiltration  may  invade  the  whole  body.  On 
the  contrary,  if  the  limbs  are  removed,  they  may  be  pre- 
served for  a  tolerably  long  time  in  a  fresh  condition. 
Butchers  know  this  peculiarity  well,  and  cut  up  their 
animals  as  soon  as  they  are  slaughtered. 

You  should  be  familiar  with  the  fact  also,  for  it  is  of  im- 
portance in  forensic  medicine. 

At  the  time  of  the  crime  of  Lebiez  and  Barre,  the  first 
experts  who  were  called,  on  seeing  the  limbs  separated  from 
the  trunk,  stated  that  the  crime  had  been  committed  quite 
recently,  for  the  portions  of  the  body  which  were  shown  to 
them  looked  fresh.  I  stated,  on  the  contrary,  that  the  state 
*  Cheyne,  'The  English  Malady.' 


APPARENT  DEATH.  29 


of  preservation  of  these  remains  was  not  sufficient  proof, 
and  that  they  might  well  belong  to  a  woman  who  had  been 
killed  a  week  before.  I  was  right ;  for,  when  the  remainder 
of  the  body  was  brought  from  Le  Mans,  the  limbs  accurately 
fitted  the  trunk,  which  was  decomposed. 

You  understand,  then,  gentlemen,  that  it  is  sometimes  ex- 
tremely difficult  to  say  whether  such  and  such  a  person  is  or 
is  not  dead.  You  will  meet  with  insurmountable  difficulties 
when  you  have  to  fix  the  time  that  has  elapsed  between  the 
moment  at  which  the  fatal  blow  was  received  and  that  at 
which  life  ceased.  Suspension  of  the  heart's  action  in  par- 
ticular is  not  sufficient  proof.  Nevertheless,  in  acute  dis- 
eases, the  moment  when  the  heart  ceases  is  evidently,  to 
within  a  few  minutes,  the  moment  of  death.  But  it  has  not 
been  shown  scientifically  that  an  individual  whose  heart  no 
longer  beats  cannot  be  recalled  to  life.  On  the  contrary,  it 
is  certain  that  some  conditions  exist  which  may  be  styled 
the  state  of  apparent  death.  We  might  definitely  choose  some 
sign  as  a  distinction  between  life  and  death,  and  use  it  in  a 
conventional  way ;  but  I  am  very  much  afraid  that,  however 
elastic  this  convention  might  be,  whatever  sign  might  be 
proposed  to  denote  the  moment  of  death,  this  sign  and  this 
convention  will  always  remain  useless  in  doubtful  cases,  and 
we  are  obliged  to  acknowledge  that  we  have  no  sign  or  group 
of  signs  sufficient  to  determine  the  moment  of  death  with 
scientific  certainty  in  all  cases. 


LECTURE  11. 

THE  UNCEETAINTY  OF  THE  SIGNS  OF  DEATH,  AND 
PREMATURE  BURIAL. 

Gentlemen, — All  these  matters  have  a  very  close  bearing  on 
the  question  of  premature  interment.  In  speaking  of  this  sub- 
ject, I  shall  purposely  leave  on  one  side  everything  that  is  at 
all  legendar}^  Stories  of  miracles  and  resurrections  are  to  be 
found  at  the  origin  of  every  religion.  These  are  articles  of 
faith,  which  it  does  not  concern  me  to  discuss  here.  Nor 
shall  I  linger  any  more  over  the  tales  of  the  fakirs  of  India. 
You  know  that  these  fakirs,- by  practising  rapid  rotation,  or 
by  howling,  get  themselves  into  such  a  peculiar  nervous  con- 
dition that  they  appear  to  be  destitute  of  life,  and  success- 
fully withstand  a  certain  number  of  tests.  One  of  these 
performances,  and  by  no  mea^is  the  least  of  them,  is  to 
allow  themselves  to  be  buried  for  two  or  three  weeks.  At 
the  end  of  this  time  the  fakir  is  disinterred  and  returns  to 
life.  I  can  neither  affirm  nor  deny  anything  about  them,  as 
I  have  not  seen  them  myself.*  I  shall  not  occupy  myself 
with  them  any  longer.  We  have  man}'  other  matters  await- 
ing consideration. 

*  The  apparent  death  of  the  fakirs  is  the  subject  of  an  interesting 
report  presented  by  Dr.  Kuhn  to  the  Anthropological  Society  of  Munich. 
From  his  report  we  extract  the  following  passages : 

'  Fakir  is  an  Arabic  word  signifying  beggar.  This  term  has  been 
applied  later  to  Indian  conjurers  as  well. 

'Although  one  may  be  led  to  believe  that  the  fakirs  practise  the 
simulation  of  death  on  a  large  scale,  the  author  of  the  report  is  none  the 
less  of  opinion,  with  a  knowledge  of  the  facts,  that  authentic  cases  are 


THE  UNCERTAINTY  OF  THE  SIGNS  OF  DEATH.        31 


UNCERTAINTY  OF  THE  SIGNS  OF  DEATH. 

The  uncertainty  of  the  signs  of  death  has  occupied 
universal  attention  for  a  very  long  time.  Parrot*  has  set 
forth  the  history  of  the  question  with  many  details. 

comparatively  rare.  He  has  had  the  opportunity  during  his  extensive 
travels  of  observing  two  undoubted  cases.  These  were  the  cases  of  two 
fakirs,  one  of  whom  had  remained  alive  under  the  ground  for  six  weeks, 
the  other  for  ten  days.  The  reporter  is  convinced  that  the  state  of  the 
fakir,  which  he  induces  by  artificial  means,  is  in  all  respects  identical 
with  that  known  as  catalepsy. 

'  The  cataleptic  state  may  last  for  hours,  days  or  months. 

'  Catalepsy  may  constitute  one  of  the  phases  of  hypnotism.  .  .  . 

'  In  the  fakirs  we  have  nearly  always  to  deal  with  this  last  form  of 
catalepsy,  when  we  have  to  explain  the  phenomenon  known  as  apparent 
death. 

'  To  attain  to  this  condition,  the  fakirs,  who  are  evidently  confirmed 
hysterical  subjects,  employ  every  means  of  exciting  a  condition  of  ecstasy, 
mortification  of  the  flesh  by  a  special  dietary,  the  internal  use  of 
different  vegetables  known  only  to  themselves,  and  a  special  posture  of 
the  body  maintained  for  many  hours.  (All  the  rules  prescribed  by 
religion  to  gain  the  power  of  entering  into  communication  with  the 
Divinity  are  to  be  found  in  the  Indian  book,  "  Hathayoga  pradipika 
Sratmaramas,'  translated  by  Dr.  H.  Walter.)  When  the  fakir  has  had 
sufficient  practice,  he  is  put  into  the  ground,  takes  one  of  the  doses 
prescribed  by  the  sacred  book,  and  falls  into  a  state  of  hypnotism  by 
means  of  fixedly  regarding  the  end  of  his  nose. 

'  The  fakirs  appear  still  to  use  hashish  to  lessen  the  energy  of  respira- 
tion, and  that  hypnotic,  combined  with  other  vegetable  drugs,  and 
employed  in  a  particular  fashion,  compensates  the  want  of  air  and 
nourishment. 

'At  the  beginning  of  hypnosis  the  fakir  has  hallucinations.  He  hears 
sounds  and  sees  angels,  his  face  expressing  a  feeling  of  beatitude.  But 
little  by  little  consciousness  vanishes,  and  the  body  acquires  a  special 
rigidity  in  proportion  as  "  the  spirit  goes  to  join  the  soul  of  the  world." 

'Dr.  Schrenk-Notring  has  replied  to  the  narrator,  adding  that  in  the 
picture  drawn  by  Dr.  Kuhn  he  has  dealt  simply  with  auto-hypnosis  in 
hysterical  persons  wrought  up  to  a  sufficient  pitch  of  excitement.  His 
conclusions  agree  with  those  of  Dr.  Kuhn  in  considering  that  narcotics 
play  a  large  part  in  bringing  about  the  state  of  hypnotism  in  fakirs. 

'  In  studying  the  hypnotic  state,  adds  Dr.  Notring,  we  frequently  meet 
with  cases  and  facts  which  afford  an  explanation  of  the  Indian  miracles' 
{Zeiischrift fiir  Hyp7totis7nus,  Berlin,  1894,  and  An?i.  de Psych,  ci  d'Hypn., 
May,  1894). 

*  J.  Parrot,  '  De  la  Mort  apparente,'  thesis  for  the  Fellowship  {agre- 
gation)  of  the  Faculty  of  Medicine  of  Paris,  March  5,  i860.     Paris,  i860. 


32  THE  SIGNS  OF  DEATH. 

The  first  philosopher  whose  opinion  on  the  subject  has 
come  down  to  us  is  Democritus,  who  averred  that  there  was 
no  certain  sign  of  the  cessation  of  Hfe.  Paul  Zacchias  and 
many  others  coincided  with  this  view.  But  it  was  not  till 
1742  that  the  public  at  large  began  to  take  an  interest  in 
these  discussions.  Winslow  had  just  declared  that  he  had 
actually  been  put  into  his  coffin  twice,  and  he  has  recorded, 
in  a  memoir  that  has  been  celebrated  ever  since,  the  anguish 
that  he  felt  at  the  time.  Bruhier,  a  physician  living  at 
Poitiers,  who  commented  on  Winslow's  work,  gave  his 
support  to  the  view  that  the  signs  of  death  are  uncertain, 
and  based  his  arguments  on  a  considerable  number  of  cases. 
His  book  made  a  great  stir;  but  Bruhier  had  accumulated 
all  the  descriptions  and  tales  that  he  could  get  hold  of,  and 
derived  some  fantastic  statistics  therefrom  ;  he  reckoned, 
for  example,  that  52  persons  had  been  buried  prematurely ; 
4  had  had  their  bodies  opened  during  life,  in  the  course  of 
autopsies  made  by  over-hasty  physicians  ;  102  had  returned 
to  life  after  a  more  or  less  prolonged  period  of  apparent 
death. 

Let  us  say  at  once  that  one  fact  is  found  to  be  almost  con- 
stantly present  :  viz.,  in  the  immense  majority  of  cases  the 
persons  died  without  having  been  seen  during  their  illness 
by  a  physician,  and  were  buried  without  a  physician  having 
had  the  opportunity  of  verifying  their  death. 

You  know  that  each  row  of  bodies  in  a  cemetery  is  dug  up 
ever}^  five  years  to  m.ake  room  for  fresh  interments.  The 
corpses  thus  disinterred  are  all  put  together  in  a  single 
trench.  It  was  under  such  circumstances  that  Tourette, 
who  was  Professor  of  Medical  Jurisprudence  in  this  Univer- 
sity, found  in  the  charnel-house  of  the  Innocents  sundry 
remains  which  occupied  a  different  position  in  their  coffins 
from  that  in  which  they  had  been  placed  :  the  idea  of  pre- 
mature burial  naturally  came  into  his  mind. 

One  thing  is  wanting  in  these  accounts,  viz.,  a  history  of 
the  patient,  with  notes  of  his  illness  ;  some  diseases  that 
we  are  well  acquainted  with — cholera  among  them — are 
followed  by  post-mortem  contortions  and  convulsions  which 
may  attain  a  considerable  degree  of  force  :  displacement  of 


THE  UNCERTAINTY  OF  THE  SIGNS  OF  DEATH.        33 

the  limbs  from  this  cause  does  not  prove  that  a  person  has 
survived  burial.  As  to  those  stories  of  post-mortem  examina- 
tions having  been  practised  by  anatomists,  when  in  too 
great  a  hurry,  on  persons  still  alive,  though  in  a  state  of 
apparent  death,  I  believe  they  are  false,  or  invented  for 
amusement.  I  will  cite  two.  One  of  them  has  for  its  hero 
the  illustrious  Vesalius.  Happening  to  be  at  the  Court  of 
Philip  II.,  he  wished  to  perform  an  autopsy  on  the  body  of 
a  gentleman,  who  awoke  under  his  scalpel.  The  affair  was 
noised  abroad,  the  Grand  Inquisitor,  it  is  said,  arrested  and 
imprisoned  Vesalius,  who  was  finally  condemned  to  go  on 
a  pilgrimage  to  Jerusalem  to  expiate  his  offence. 

When  this  story  was  again  investigated  some  years  ago 
by  a  biographer  of  Vesalius,  it  was  discovered  to  be  false. 
Vesalius  was  never  thrown  into  the  dungeons  of  the  Inquisi- 
tion, and  he  himself  applied  to  Philip  II.  for  leave  to  visit 
the  Holy  Land. 

The  second  case  is  that  of  Abbe  Prevost,  who  fell  down 
dead  in  the  woods  of  Clamart ;  a  medical  man,  who  did  not 
employ  sufficient  delay,  opened  the  abdomen  to  discover  the 
cause  of  this  unexpected  death,  whereupon  Abbe  Prevost 
awoke.  He  is  said  to  have  been  cured,  and  to  have  lived 
many  years  after. 

Now,  this  Abbe  had  been  tutor  in  the  family  of  Firmin- 
Didot  ;  M.  Tourdes,*  who  is  now  the  Honorary  Dean  of 
the  Faculty  at  Nancy,  was  closely  connected  with  this 
family;  he  has  interrogated  the  members  of  it  at  length,  yet 
no  one  was  found  who  remembered  that  Abbe  Prevost  had 
ever  related  this  episode  of  his  life,  although  it  was  so 
unique  that  no  one  could  help  preserving  the  recollection 
of  it. 

What  has  generally  given  rise  to  these  legends  is  that  the 
persons  who  have  been  the  chief  actors  in  them  have  been 
buried  without  any  medical  man  having  verified  the  fact 
that  life  had  actually  ceased ;  if  a  mistake  has  been  made,  it 
is  a  popular  blunder,  not  a  medical  one. 

As  a  result  of  the  outcry  raised  by  Winslow  and  Bruhier, 
whose  opinions  gained  a  great  hold  even  outside  France,  the 

*  Tourdes,  '  Dictionnaire  encyclopEedique  des  Sciences  medicales.' 

3 


34  THE  SIGNS  OF  DEATH. 

so-called  mortuary  chambers  were  instituted  in  Germany. 
What  is  a  '  mortuary  chamber  '  ?  A  person  dies  :  he  is 
carried  to  an  apartment  called  the  '  mortuary  chamber,' 
where  he  is  surrounded  with  flowers,  and  a  bell-rope  is 
placed  in  his  hand  ;  moreover,  an  attendant  visits  the  place 
from  time  to  time  to  inspect  the  corpse.  Gentlemen,  from 
the  time  that  mortuary  chambers  were  instituted — and  that 
at  Weimar  dates  from  1792 — neither  at  Weimar  nor  at 
Munich  (these  are  the  mortuary  chambers  that  I  have 
personally  visited),  nor  anywhere  else,  I  believe,  has  anybody 
ever  rung  that  bell.  It  ma}^  be,  and  has  been,  said  in  reply, 
that  the  dead  bodies  brought  to  these  places  have  always 
been  seen  by  medical  men,  and  that  the  safeguard  which  has 
been  conferred  upon  them  is  superfluous ;  we  do  not  deny 
the  force  of  this  objection,  but  we  are  perfectly  justified  in 
concluding  that  cases  of  apparent  death  must  be  very  rare 
indeed. 

The  mortuary  in  Germany  is  a  place  whither  corpses  are 
carried  in  order  to  make  sure  that  death  has  really  taken 
place.  In  France  mortuaries  exist  also,  but  with  quite  a 
different  purpose.  There  are  two  of  them  in  Paris.*  They 
have  been  established  in  order  that  persons  might  be 
removed  there  who,  having  only  one  room  for  themselves 
and  their  family,  die  in  the  same  apartment  where  the 
members  of  the  family  will  have  to  perform  all  their  natural 
duties  by  the  side  of  the  corpse,  greatly  to  the  detriment 
of  health  and  morality.  I  remember,  as  an  instance  of  this, 
the  following  occurrence :  A  man  died  of  small-pox  ;  his 
family  and  friends  watched  the  body ;  they  ate  and  drank 
by  its  side,  and  when  I  came  to  see  the  man,  of  whose 
death  I  had  not  been  informed,  there  were  bottles  every- 
where, even  on  the  abdomen  of  the  deceased.  Do  not  take 
this  as  an  isolated  case  ;  it  is,  on  the  other  hand,  very 
frequent,  and  the  cause  of  demoralization.     It  is  the  chief 

*  Decree  of  April  27,  1889,  on  the  conditions  applicable  to  the  different 
modes  of  burial.  'Art.  5. — It  is  lawful  to  establish  funeral  chambers 
intended  for  the  reception  before  burial  of  the  bodies  of  persons  whose 
death  has  been  caused  by  an  infectious  disease  ;  the  funeral  chambers 
are  to  be  established  on  the  demand  of  the  Municipal  Council,'  etc. 


THE  UNCERTAINTY  OF  THE  SIGNS  OF  DEATH.        35 

reason  which  has  urged  us  to  demand  the  institution  of 
mortuaries ;  they  are  necessary,  as  a  matter  of  fact,  to 
insure  proper  respect  towards  death,  and  observance  of  the 
precepts  of  hygiene. 

Oriila,  Fodere,  and  Michel  Levy,  all  believed  in  the  pos- 
sibility of  premature  burial,  and  it  is  certain  that  it  cannot 
be  denied    absolutely.     Against   the   partisans    of    the    un- 
certainty of  the  signs  of  death  we  may  set  some   authors 
who  affirm  that  the  signs  of  death  are   unmistakable.     At 
the  head  of  them  I  will  place  Celsus,  whose   criticism  of 
Democritus  I  quote  here :  '  If  the  apparent  identity  of  certain 
signs  deceives  an  unskilful  physician,  an  experienced  and 
intelligent    man    cannot    be    mistaken  ;    and   the    case    of 
Asclepiades,  w^ho  recognised,  on  meeting  a  funeral  proces- 
sion, that  the  person  whom  they  were  going  to  bury  was 
still  alive,  is  a  proof  of  this.     The  faults  of  an  artist  are  not 
defects  of  the  art.'     I  will  also  cite  Lancisi,  and  above  all 
Louis,  who  in  a  voluminous  memoir  concludes  in  the  follow- 
ing terms:   'The  opinion  that  the  signs  of  death   are  not 
certain  is  too  dangerous  to  be  true.'     Notwithstanding  all 
the  respect  that  I  have  for  the  memory  of  Louis,  his  con- 
clusion seems  to  me  a  singular  one,  and  as  unscientific  as 
that  of  Celsus.     It  is  much   better   to  acknowledge   one's 
ignorance  than  to    mask  it  by  an   aphorism   of  this  sort. 
Louis  adds  :    '  I   know   of  only  one  doubtful  instance.     It 
was  that  of  a  woman  who  was  delivered  of  a  child  at  her 
own  home,  and  who  was  afterwards  removed  to  the  Hotel- 
Dieu.      There   was    no    room    for   her   there,    so    she    was 
directed  to  go  on  to  the  Salpetriere,  which  she  did  on  foot. 
On  the  way  she  fainted  three  times,  and  careful  note  was 
taken  of  the  places  where  these  attacks  of  S3mcope  occurred. 
She  reached  the  Salpetriere,  and  immediately  died,  or  at  any 
rate  was  taken  very  ill  for  the  fourth  time.     She  was  carried 
to   the    dead-house.      The    house-physician    under    Louis 
entered  the  vault  some  time  after  to  practise  surgical  opera- 
tions, and  found  the  woman  half  extricated  from  the  cover- 
ing that  had  been  thrown  over  her,  and  struggling  on  the 
slab  whereon  she  was  placed.     He  called  out,  and   Louis 
himself  ran  up  and  found  that  the    unhappy  woman   had 


36  THE  SIGNS  OF  DEATH. 

one  foot  off  the  slab,  and  one  arm  out  of  the  sheet.  She 
was  still  warm,  but  by  this  time  she  was  quite  dead. 

Are  there  any  cases  in  which  medical  men  themselves 
have  failed  to  recognize  a  state  of  apparent  death,  and  do 
these  cases,  if  any  such  exist,  entitle  us  to  demand  a  reform 
in  the  law  of  burial,  or  may  we  rest  satisfied  with  the 
present  arrangement  of  things  ? 

Here  is  a  case  to  start  with  :  Dr.  Rigaudot,  in  practice 
in  the  suburbs  of  Douai,  and  a  thoroughly  honourable  man, 
was  summoned  to  a  woman  who  was  about  to  be  confined. 
On  his  arrival  he  was  told  that  the  woman  had  been  dead 
two  hours.  Thinking  that  it  might  be  possible  to  save  the 
child.  Dr.  Rigaudot  ruptured  the  membranes,  and  brought 
into  the  world  a  child,  which  was  raised  to  life  with  some 
difficulty.  It  took  him  half  an  hour  to  accomplish  this. 
He  asked  to  see  the  mother  again,  to  whom  no  one  was 
paying  any  more  attention,  and  who  had  been  already  laid 
out ;  he  noticed  that  the  body  was  warm,  and  then  went 
away.  Some  hours  later,  in  the  evening,  that  woman 
returned  to  life;  but  as  a  result  of  the  accident  she  remained 
deaf,  nearly  blind,  and  almost  an  idiot.  This  physician, 
therefore,  whose  report  may  be  believed,  was  confronted  by 
two  cases  of  apparent  death,  viz.,  that  of  the  mother  and 
that  of  the  child. 

In  1866  a  petition  was  presented  to  the  Senate  with 
reference  to  premature  burials.  Cardinal  Dounet,  in  a 
sermon  which  made  a  great  impression,  assured  his  hearers 
that  he  himself  had  rescued  two  girls  from  the  grave ;  more- 
over, he  narrated  the  following  history,  which  roused  pro- 
found emotion  :  '  In  1826  a  young  priest,  while  preaching 
in  a  crowded  cathedral,  suddenly  sank  down  in  a  swoon  in 
the  pulpit.  A  physician  pronounced  that  death  had  taken 
place,  and  drew  up  the  form  for  his  burial  the  next  day. 
The  Bishop  of  the  cathedral  where  the  occurrence  happened 
had  begun  to  recite  the  De  Profundis  at  the  foot  of  the 
bier,  and  the  body  had  been  measured  for  a  coffin.  As 
night  approached,  the  agony  of  the  young  priest  may  be 
imagined  when  his  ear  caught  the  sound  of  these  prepara- 
tions.    At  length  he  heard  the  voice  of  one  of  the  friends 


THE  UNCERTAINTY  OF  THE  SIGNS  OF  DEATH.        37 

of  his  childhood  ;  this  voice  excited  him  to  make  a  super- 
human effort,  and  a  marvellous  result  ensued.  The  next 
day  he  was  able  to  reappear  in  the  pulpit.  To-day  he  is  in 
your  midst  (sensation)  entreating  you  to  demand  of  your 
representatives,  not  only  to  take  care  that  the  provisions 
of  the  law  are  complied  with,  but,  furthermore,  to  enact 
additional  ones  that  shall  prevent  these  misfortunes  which 
are  too  frequent  and  irreparable.'*  In  this  case,  had  an 
attack  of  syncope,  or  an  inhibition  caused  by  the  violent 
emotion  of  preaching  in  a  cathedral,  been  mistaken  for 
apparent  death  ?  I  do  not  know,  but  the  story  must  be 
accepted  as  true. 

Other  cases  have  an  equal  title  to  be  put  on  record. 

Dr.  Roger,  of  Plougonven  (a  suburb  of  Morlaix),  relates 
the  following  incident :  In  1866,  while  cholera  was  raging  in 
the  department  of  Morbihan,  a  young  woman,  aged  26,  was 
suddenly  seized  with  pain  in  the  head  and  various  other 
symptoms,  and  her  condition  rapidly  became  serious.  The 
people  around  her  believed  that  she  had  got  cholera,  and 
before  many  hours  had  elapsed  she  died.  She  was  laid  out 
and  placed  in  a  coffin,  and  sixteen  hours  after  death  her 
burial  took  place ;  a  noise  was  heard  inside  the  coffin  which 
attracted  attention.  Dr.  Roger  was  summoned ;  he  had 
the  coffin  opened,  and  found  that  life  remained ;  he  had  the 
woman  removed  into  the  church,  as  it  was  impossible  to 
carry  her  all  the  way  home  on  account  of  the  distance ;  he 
was  unsparing  in  his  attentions,  but  she  died  in  the  course 
of  the  night  and  was  buried  in  earnest  the  following  day. 

'  This  observation,'  says  M.  Tourdes,  '  seemed  to  us  a 
well-authenticated  case  of  the  burial  of  a  living  person.  To 
make  quite  sure,  we  commaunicated  with  Dr.  Roger,  the 
witness  of  the  incident,  and  received  from  him  the  following 
reply,  dated  July  30,  1874  :  "  Yes,  I  was  present  at  the  ex- 
humation of  a  woman  buried  in  a  state  of  apparent  death. 
I  did  not  hear  the  sounds  of  the  heart  distinctly,  though  on 
auscultation  I  plainly  perceived  some  faint  rhythmical 
movements  in  the  prsecordial  region  ;  I  am  positive  that  the 
woman  was  still  alive  when  I  examined  her,  it  is  not  a  mere 
*  Moiiitetir,  March  I,  1866,  p.  238. 


38  THE  SIGNS  OF  DEATH. 

probability.  Here  is  a  verbatim  copy  of  the  notes  taken  the 
same  evening:  '  Plouigneau,  Oct.  i,  1867,  midnight. —  I 
exhumed  at  8  p.m.  Philomele  Jonetre,  aged  24,  buried  at 
5  p.m.  in  a  grave  6  feet  in  depth.  Several  persons  heard 
her  tap  distinctly  against  the  lid  of  the  cofBn ;  these  blows 
appear  to  me  to  have  left  visible  marks,  but  I  did  not 
hear  them  m3'self.  There  was  no  smell,  no  evacuation,  but 
abundant  evidence  of  respiration.  Distinct  rhythmical 
sound  in  the  region  of  the  heart.  No  rigor  mortis  ;  muscular 
contractions  of  the  arms  present,  as  well  as  in  the  lower 
jaw ;  heat  and  colour  of  the  skin  normal ;  no  film  on  the 
cornea  ;  tissues  of  the  hand  transparent  to  the  light  of  the 
candle  I  held.  Ammonia  was  applied  to  the  nose  ;  alternate 
compression  and  relaxation  applied  to  the  chest.  She  was 
not  dead,  but  like  a  candle  the  flame  of  which  has  been  ex- 
tinguished, though  the  wick  continues  to  glow.  No  definite 
sounds  of  the  heart ;  the  eyelids  moved  in  my  presence.  I 
kept  her  unburied  until  the  following  day.'  "  It  is  out  of 
these  notes  that  the  account  has  been  compiled ;  it  is  an 
authentic  case  of  burial  during  life.  Without  doubt,  if  a 
physician  had  seen  her  at  the  commencement  of  her  illness, 
if  the  supposed  death  had  been  properly  verified,  if  the  body 
had  not  been  placed  in  the  coffin  within  an  hour  of  the  sup- 
posed death,  and  if  burial  had  not  been  proceeded  with 
within  sixteen  hours  (though  this  was  contrary  to  law),  the 
mistake  would  not  have  been  made ;  but  the  same  set  of 
circumstances  may  happen  again,  during  an  epidemic  in  the 
provinces,  where  verification  is  not  systematically  carried 
out,  and  it  is  useful  to  have  it  demonstrated,  by  a  fresh  case, 
that  the  danger  of  being  buried  ahve  is  not  chimerical.' 

Without  being  as  confident  as  M,  Tourdes,  it  cannot  be 
denied  that  the  fact  is  within  the  range  of  possibility. 

The  case  of  General  Ornano  is  well  known.  During  the 
retreat  from  Russia  General  Ornano  had  his  head  grazed 
by  a  bullet  while  in  the  act  of  charging  the  enemy  at  the 
head  of  his  squadron  ;  he  fell  from  his  horse,  and  his  orderly, 
Captain  Tacher,  ran  to  his  assistance,  but  found  that  he 
showed  no  signs  of  life,  and  buried  him  under  a  heap  of 
snow,  having  no  time  to  afford  him  a  more  becoming  inter- 


THE  UNCERTAINTY  OF  THE  SIGNS  OF  DEATH.        39 

ment.  The  orderly  then  went  to  announce  the  death  to 
Napoleon.  Two  hours  afterwards  General  Ornano  came  to 
report  himself  to  the  Emperor  ;  he  lived  a  long  time  after, 
and  was  one  of  the  pall-bearers  of  his  old  orderly  Tacher, 
who  had  in  due  course  become  a  General. 

The  following  case  is  probably  one  merely  of  syncope  or 
prolonged  nervous  commotion  :  In  1848,  as  Louis  Philippe 
was  leaving  the  Tuileries  to  go  into  exile,  the  bodies  of 
three  National  Guards  were  lying  at  the  gates  of  the  garden, 
near  the  Place  de  la  Concorde ;  wishing  to  spare  the  King 
any  fresh  grief,  some  persons  good-naturedly  buried  these 
bodies  under  a  heap  of  sand.  When  they  were  extricated, 
some  hours  after,  one  of  these  men  was  still  alive. 

These  cases  have  great  probability,  but  perhaps  they  are 
not  altogether  beyond  dispute  ;  about  two  of  them,  gentle- 
men, there  can  be  no  doubt  at  all,  for  they  were  under  the 
supervision  of  medical  men.  The  first  is  related  in  Parrot's 
thesis,  of  which  I  lately  spoke  to  you ;  here  it  is  in  full ;  it 
relates  to  an  individual  who  was  hanged  at  Boston  in  1858, 
and  was  observed  by  Drs.  Clark,  Ellis  and  Shaw  : 

'  The  executed  man  weighed  130  pounds,  was  28  years  of 
age,  and  very  robust.  The  hanging  took  place  at  10  a.m. 
It  is  stated  that  there  was  neither  any  struggling  nor  con- 
vulsion. We  must  remark  that,  while  admitting  that  the 
spectators  may  have  been  too  much  affected  to  have  been 
able  to  study  what  took  place  with  all  necessary  attention, 
it  must  be  allowed  at  any  rate  that  death  took  place  without 
any  very  obvious  convulsions,  for  if  there  had  been  such,  no 
degree  of  emotion  could  have  prevented  them  from  being 
seen.  Their  absence  is  an  interesting  feature  which  shows 
that  death  was  not  brought  about  by  rapid  asphyxia,  a  con- 
dition which  is  always  attended  by  violent  convulsions. 

'  In  this  man  who  was  hanged  at  Boston,  the  lungs  and 
brain  were  found  to  be  normal.  How,  then,  did  death  take 
place  ?  Without  the  slightest  doubt  its  primary  cause  was 
sudden  syncope  from  emotion  or  from  excitation  of  the 
brain  produced  by  the  drop  (7  or  8  feet)  at  the  moment  of 
hanging ;  while  the  body  was  still  hanging,  seven  minutes 
from  the  commencement,  the  sounds  of  the  heart  could  be 


40  THE  SIGNS  OF  DEATH. 

heard,  beating  at  the  rate  of  lOO  per  minute.  Two  minutes 
later  the  rate  was  98,  and  three  minutes  after  only  60  and 
very  feeble.  In  two  minutes  afterwards  the  sounds  had 
disappeared. 

'  At  10.25  '^•"^-  the  body  was  taken  down  :  there  was  no 
more  sound  or  impulse  of  the  heart ;  the  face  was  purple, 
although  a  small  space  near  the  ear  probably  allowed  the 
passage  of  blood.  The  tongue  and  eyes  did  not  protrude  ; 
the  pupils  were  dilated.  The  rope  had  been  applied  just 
above  the  thyroid  cartilage.  At  10.40  a.m.  the  rope  was 
untied,  as  well  as  the  pinions  which  bound  the  arms  to  the 
sides.  This  done,  the  face  and  body  gradually  became  pale. 
The  vertebral  column  had  not  been  broken.  There  was  no 
emission  of  semen — a  fact  in  harmony  with  the  absence  of 
asphyxia  and  of  lesions  of  the  spinal  cord. 

'  At  11.30  a.m.  a  regular  pulsation  was  noticed  in  the  right 
subclavian  vein  (?  artery).  On  putting  the  ear  close  to  the 
chest,  one  could  make  certain  that  this  depended  entirely  on 
the  heart,  and  a  single  beat  could  be  heard  80  times  per 
minute,  regular  and  distinct  and  accompanied  by  a  slight 
impulse.  The  thorax  was  then  opened,  a  proceeding 
which  did  not  excite  any  pulsatile  movements.  The  right 
auricle  was  contracting  and  dilating  with  force  and  regu- 
larity. 

'At  12  in.  the  number  of  pulsations  was  40  per  minute; 
at  1.45  p.m.  5  per  minute.  The  spontaneous  movements 
ceased  at  2.45  p.m.,  and  irritability  persisted  till  ^.18  p.7n., 
more  than  five  hours  after  the  hanging.' 

Although  Dr.  Clark  does  not  say  so,  it  is  infinitely  probable 
that  the  sound  heard  on  auscultation  before  the  thorax  was 
opened  was  due  to  movements  of  the  right  auricle,  and  not 
of  the  ventricles. 

That  is  the  first  case.  I  must  point  out,  in  passing,  the 
strange,  cool  manner  in  which  these  Boston  physicians 
performed  their  experiments  on  a  living  man.  But  it  cannot 
be  denied  that  this  man  was  hanged,  his  death  was  witnessed 
by  medical  men,  and  yet  this  man  showed  indisputable  signs 
of  the  persistence  of  life. 

The   second    case    resembles   the   first ;    it    happened   at 


THE  UNCERTAINTY  OF  THE  SIGNS  OF  DEATH.        41 

Pesth,  and  is  reported  by  Hofmann  ;*  it  also  happened  in  a 
criminal  sentenced  to  be  hanged  ;  he  had  round  his  neck 
enlarged  glands,  which  probably  partly  neutralized  the  con- 
striction of.  the  slip-knot  which  encircled  it.  However  that 
may  have  been,  the  body  remained  suspended  for  twenty 
minutes,  a  medical  man  certified  that  death  had  occurred, 
and  the  body  of  the  executed  man  was  transported  in  a  van 
at  a  rapid  pace  to  the  post-mortem  room ;  there  was  some 
distance  to  go,  and  when  the  van  arrived,  the  physicians, 
who  were  expecting  a  corpse,  were  greatly  surprised  to  see 
instead  of  a  corpse  an  individual  who  raised  himself  up 
before  them,  and  looked  at  them  with  a  scared  expression  : 
the  executed  man  had  returned  to  life.  A  telegram  was 
sent  to  the  Minister  of  Justice  to  ask  for  instructions,  and 
the  Minister  in  reply  told  them  to  wait  and  see  what 
happened.  It  was  not  necessary  to  wait  very  long,  for 
three  or  four -hours  afterwards  the  man  died  of  pulmonary 
congestion,  evidently  a  result  of  the  hanging. 

In  both  these  cases  the  error  was  a  medical  one  :  it  is 
impossible  to  doubt  that  a  blunder  was  made,  precisely  because 
examination  by  a  medical  man  had  not  been  omitted. 

There  is  yet  a  third  series  of  cases  of  more  or  less  apparent 
death,  concerning  which  I  must  say  a  few  words  to  you. 
Gentlemen,  the  child  that  is  born  into  the  world  in  a  state 
of  apparent  death  is  not  ahvays  still-born ;  you  are  well 
aware  that  many  of  these  '  still-born  '  infants  may  be  re- 
called to  life.  Depaul,  who  has  left  a  minute  and  careful 
record  of  such  cases,  succeeded  in  restoring  new-born 
children  by  means  of  pulmonary  insufflation,  an  hour  and  a 
half,  two  hours,  or  even  three  hours,  after  the  heart  had 
ceased  to  beat. 

It  is  necessary,  therefore,  to  remind  you  that  apparent 
death  is  tolerably  frequent  at  the  moment  of  birth,  and  that, 
with  prolonged  care,  by  means  of  insufflation,  and  also  of 
rhythmical  traction  of  the  tongue,  which  has  answered  well 
in  the  hands  of  M.  Laborde,  you  can  bring  back  to  life 
infants  that  are  apparently  dead. 

*  Hofmann,  '  Nouveaux  Elements  de  Medecine  legale,'  avec  intro- 
duction et  commentaires  par  Brouardel.     Paris,  1880. 


42  THE  SIGNS  OF  DEATH. 

To  form  a  just  judgment,  Gentlemen,  on  so  difficult  a 
question  as  that  of  apparent  death,  it  is  essential  to  eliminate 
every  source  of  error.  The  chief  of  these  arises  from  the 
persistence  of  muscular  contractions  after  death,  as  in 
cholera.  One  might  even  say  that  movement  continues 
after  death.  In  the  bodies  of  persons  who  have  died  from 
this  disease,  we  may  actually  meet  with  rhythmical  contrac- 
tions of  the  abdomen  and  of  the  muscles  of  the  thigh,  strong 
enough  to  produce  flexion  of  the  limb,  etc.  These  phenomena 
have  sometimes  made  people  doubt  the  reality  of  death. 

Gentlemen,  when  you  happen  to  be  alone  by  the  side  of  a 
corpse  at  night-time,  observe  it  well ;  you  will  notice  a 
singular  persistence  of  movements  in  the  muscles  of  the  face 
and  of  the  hands.  Abduct  the  thumb  from  the  forefinger  ; 
in  the  course  of  a  few  hours  they  will  be  approximated 
again  ;  but  do  not  conclude  from  these  facts  that  life  remains. 
I  may  say  the  same  about  contractions  of  the  diaphragm  ; 
they  may  be  energetic,  causing  an  expulsion  of  gas,  and  often 
of  liquids  (the  watchers  call  this  the  'emptying  of  the  body'), 
or  abrupt,  in  which  case  they  may  evoke  a  hiccough,  or 
sometimes  an  inarticulate  sound  or  cry. 

The  expulsion  of  semen  has  been  considered  to  be  a  proof  of 
life.  When  cadaveric  rigidity  sets  in,  it  appears  to  start  from 
the  vesiculse  seminales ;  the  semen,  owing  to  this  particular 
contraction,  is  discharged  into  the  urethra,  and  may  perhaps 
escape  externally,  according  to  the  position  of  the  penis. 
This  escape  is  therefore  no  proof  that  life  remains. 

Identical  stories  are  told  of  pregnant  women  being 
delivered  on  the  tables  of  the  mortuary.  The  observations 
which  have  been  made  by  Depaul  and  myself  clearly  demon- 
strate that  in  women  who  have  previously  been  confined, 
and  who  die  when  again  six  or  seven  months  advanced  in 
pregnancy,  the  development  of  gases  in  the  intestines  may 
lead  to  the  expulsion  of  the  foetus,  because  the  uterus 
becomes  inverted  ;  it  is  a  mechanical  phenomenon  of  putre- 
faction. 

Sometimes  the  outward  appearances  of  life  are  preserved 
in  death.  When  the  Opera-Comique  was  burnt  down, 
twenty-nine   bodies  were   found  near   the  refreshment    bar 


THE  UNCERTAINTY  OF  THE  SIGNS  OF  DEATH.        43 


which  showed  no  marks  of  burning  or  violence  ;  the  dresses, 
and  even  the  finest  lace,  were  intact ;  these  persons  had 
succumbed  to  asphyxia  by  carbonic  oxide.  When  their  faces 
had  been  cleansed  from  the  black  and  grimy  coating  which 
the  smoke  had  deposited,  three  of  them  were  found  to  be 
young  girls.  In  the  case  of  two  of  them,  their  relatives 
could  scarcely  believe  that  they  were  dead  when  they  saw 
them  ;  for  their  complexions  were  rosy  and  the  lips  red, 
because  the  carbonic  oxide  had  preserved  the  scarlet  colour 
of  the  blood ;  even  when  putrefaction  had  set  in,  a  few  days 
afterwards,  these  girls  still  had  a  rosy  look,  because  the 
red  blood  was  propelled  towards  the  head  and  face. 

Predisposition  to  Apparent  Death. — Can  we  enumerate 
and  classify  cases  of  apparent  death  ?  In  by  far  the  majority 
of  cases,  the  approach  of  death  is  known  to  those  who  have 
to  do  with  the  patient.  You  have  seen  that  danger  of 
apparent  death  is  especially  great  in  new-born  infants  ;  it  has 
been  said  to  be  possible  in  the  case  of  the  old  ;  it  is  possible 
in  the  case  of  a  large  class  of  persons  if  they  are  placed  in 
special  conditions. 

First  of  all  must  be  reckoned  those  hysterical  persons  who 
live  on  the  scantiest  supplies  of  food,  and  who  are  prone  to 
fall  into  lethargy,  and  may  remain  in  the  state  of  apparent 
death  for  a  considerable  time.  I  do  not  believe  that  a 
physician  would  commonly  be  mistaken  over  them,  for 
auscultation  of  the  heart  would  reveal  the  true  state  of 
things ;  but  ordinary  people  might  be  deceived.  Allow  me 
to  insert  a  parenthesis  here  :  In  France,  except  in  those 
towns  where  there  is  a  municipal  organization  for  the  verifi- 
cation of  death,  entrusted  to  medical  men,  the  registrar  of 
deaths  is  the  sole  person  who  is  charged  with  proving  the 
reality  of  death.  He  does  not,  as  a  rule,  perform  this  duty 
in  a  thorough-going  manner,  and  if  he  does  take  pains  to  do 
so,  he  cannot  perform  it  satisfactorily,  since  he  is  not  a 
medical  man.  There  are,  then,  under  these  conditions, 
and  particularly  in  the  country,  many  opportunities  for 
making  mistakes. 

I  next  call  your  attention  to  syncope,  or  inhibition.  A 
mass  of  literature,  comprising  more  thana  thousand  volumes 


44  THE  SIGNS  OF  DEATH. 

or  memoirs,  has  been  founded  on  this  subject,  and  the 
immense  number  of  cases  embarrasses  me  not  a  little.  One 
reads  therein  of  soldiers  wounded  in  battle  and  dying  of 
hsemorrhage,  who  have  been  restored  to  life  after  two,  three, 
four,  or  even  twelve  days  ! 

I  do  not  know  how  long  life  may  be  prolonged  after  a  fatal 
hsemorrhage ;  I  know  that  it  may  be  for  an  hour,  because  I 
have  seen  instances  of  it.  Am  I  entitled  to  deny  that  it 
may  be  prolonged  still  further  ?  Just  remember,  then,  that 
death  by  haemorrhage,  by  syncope,  or  by  inhibition,  may  be 
a  source  of  fallacy.  Cases  have  also  been  related  of  indi- 
viduals who  have  been  buried  for  two  or  three  days,  and  yet 
have  returned  to  life.  The  fact  may  sometimes  be  explained  ; 
e.g.,  the  layer  of  sand  or  of  earth  thrown  over  the  body  may 
be  permeable  to  air,  so  that  a  sufficient  quantity  for  respira- 
tion and  the  support  of  life  may  be  admitted. 

As  to  submersion,  we  know  that  drowned  persons  are 
resuscitated  every  day  by  means  of  diligent  and  well-con- 
trived efforts.  But  when  we  are  asked  to  say  how  long  these 
persons  may  have  been  submerged,  we  cannot  be  too  cautious 
in  expressing  an  opinion.  It  is  a  matter  of  estimating  prob- 
abilities. Some  assert  that  resuscitation  may  be  effected 
after  submersion  for  two,  three,  or  five  hours ;  but  people 
who  are  present  at  the  scene,  and  take  part  in  the  exertions 
that  are  being  made,  have  no  idea  of  time.  They  will  tell 
you  that  they  have  been  there  an  hour,  although  it  may  really 
be  only  a  quarter  of  an  hour  since  they  reached  the  place. 

With  regard  to  freezing,  Gentlemen,  there  are  certain  cases 
which  I  am  bound  to  accept.  A  story  is  told  of  a  grenadier 
belonging  to  the  Strasburg  garrison,  who  was  found  frozen 
in  the  river  111 ;  he  was  taken  to  the  hospital,  warmth  was 
applied,  and  he  survived.  At  Strasburg,  on  another  occasion, 
also,  a  hospital  attendant  was  found  frozen,  was  resuscitated, 
and  still  continues  his  duties,  which  he  has  now  performed 
for  many  years. 

The  after-effects  of  lightning  stroke  have  not  received  suffi- 
cient attention.  Out  of  seventy-seven  instances  related  by 
Sestier,*  there  are  six  or  seven  in  which  apparent  death 
*  Sestier,  '  De  la  Foudre.'     Paris,  1866. 


THE   UNCERTAINTY  OF  THE  SIGNS  OF  DEATH.        45 

lasted  for  five  or  six  hours.  Boudin  quotes  tlie  case  of  a 
sailor  who  was  restored  after  having  been  apparently  dead 
for  an  hour  and  a  half,  I  believe  that  the  death-like  state 
may  be  ascribed  in  these  cases  to  inhibition,  caused  by  a 
maxinmm  degree  of  stimulus,  a  possibility  which  cannot  be 
gainsaid. 

Finally,  Gentlemen,  I  come  to  cerebral  commotion,  and  I 
will  at  once  cite  to  you  two  typical  cases. 

At  the  siege  of  Constantine,  General  Trezel,  who  com- 
manded the  division,  was  struck  by  a  ball  on  the  back  of  the 
neck,  and  fell  down.  The  troops  continued  their  assault  on 
the  town,  which  presently  fell  into  the  hands  of  the  French. 
Search  was  then  made  for  the  General's  body.  It  was  found, 
and  placed  on  a  stretcher.  While  being  carried  on  the 
ambulance,  the  General  returned  to  life  and  warmly  thanked 
the  porters,  but  he  did  not  recollect  that  he  had  been 
wounded.  How  long  did  apparent  death  last  in  his  case  ? 
I  do  not  know  ;  but  I  can  state  positively  that  it  lasted 
during  the  time  necessary  to  take  the  town,  which  must 
have  occupied  some  hours  at  least. 

The  second  case  came  under  my  own  eyes,  and  took  place 
while  I  was  house-physician  at  La  Pitie.  At  that  time 
the  resident  staff  were  not  on  good  terms  with  the  adminis- 
tration. A  little  bricklayer,  aged  13,  was  brought  in  one 
day,  who  had  fallen  from  the  sixth  story  on  to  the  pave- 
ment. The  accident  happened  in  the  Rue  de  la  Tournelle. 
The  boy  had  been  taken  to  a  chemist,  who  pronounced  him 
to  be  dead,  and  sent  him  on  to  the  hospital.  The  director 
refused  to  admit  him,  as  he  was  dead.  Now,  either  by 
intuition  or  else  to  bamboozle  the  director,  I  stated  that 
the  lad  was  alive,  although  the  sounds  of  the  heart  could 
not  be  heard  on  auscultation.  I  had  him  put  into  a  mustard 
bath,  and,  to  my  delight,  he  came  to.  He  had  received  no 
wound  or  any  definite  injury,  only  he  remembered  nothing. 
Gentlemen,  I  presume  that  an  hour  and  a  half  had  elapsed 
between  the  time  that  he  fell  and  that  when  he  entered  the 
hospital.  Just  think  that  he  had  first  been  carried  to  the 
chemist's,  who  had  examined  him ;  next,  that  a  stretcher 
had  to  be  procured  ;  and  then  there  was  a  good  deal  of 


46  THE  SIGNS  OF  DEATH. 

parleying  at  the  hospital  door.  That  lad  suffered  from 
cerebral  concussion,  whence  he  emerged  suddenly  without 
any  outward  trouble.  He  might  have  been  buried  alive ;  he 
might  perhaps  have  returned  to  life  beforehand.  I  hope  he 
would  have  done  so,  though  I  dare  not  feel  sure. 

Some  authors  have  described  poisoning  by  the  fumes  of 
charcoal  as  being  capable  of  inducing  a  state  comparable  to 
that  of  apparent  death.  Dr.  Harmand  (of  Nancy)  relates 
that  he  was  called  to  a  coachman,  who  gave  no  sign  of  life, 
and  that  another  medical  man  who  had  been  called  in  before 
had  pronounced  that  the  patient  had  succumbed  to  cerebral 
congestion.  Noticing  the  peculiar  odour  which  pervaded 
the  room,  Dr.  Harmand  had  the  windows  opened,  and 
devoted  his  full  attention  to  the  restoration  of  the  patient, 
who  returned  to  life  and  still  survives.  He  attributes  the 
coachman's  illness  to  poisoning  by  charcoal  fumes. 

Gentlemen,  when  a  person  is  killed  by  charcoal  fumes,  he 
is  poisoned  by  carbonic  oxide,  not  by  carbonic  acid.  When 
anyone  is  placed  in  an  atmosphere  of  carbonic  acid,  death 
happens,  not  from  poisoning,  but  because  the  atmosphere 
has  become  irrespirable. 

I  can  relate  to  you  some  curious  experiments  under  this 
head.  A  Commission  in  which  I  took  part,  with  MM. 
Schutzenberger,  du  Mesnil,  and  others,  was  charged  to  give 
an  account  of  the  poisonous  nature  of  the  gases  contained 
in  the  soil  of  cemeteries.*  We  caused  graves  to  be  dug 
13  to  i6|  feet  deep.  In  some  of  these  graves  we  had  corpses 
buried  ;  others  we  left  empty  as  control  experiments.  We 
wanted  to  measure  the  amount  of  carbonic  acid  and  other 
gases  liberated  in  these  graves.  In  the  soil  of  Paris,  satur- 
ated with  animal  matter,  and  still  more  with  vegetable  matter 
in  a  state  of  decomposition,  we  detected  as  much  carbonic 
acid  in  the  empty  graves  as  in  those  which  contained  the 
corpses.  One  grave,  i6j  feet  deep,  was  full  of  carbonic  acid 
in  five  hours.  Graduated  candles  burned  in  them  for  only 
ten  or  fifteen  minutes  at  the  bottom  ;  at  the  upper  part  they 

*  Brouardel,  '  Projet  de  Creation  d'un  nouveau  Cimetiere  h.  Boulogne- 
sur-Seine'  {A/ni.  d'Hyg.,  1886).  Brouardel  et  du  Mesnil,  'Conditions 
d'Inhumation  dans  les  Cimetieres  :  R^forme  du  Ddcret  de  Prairialsur  las 
Sepultures'  {Ann.  d'Hyg..  1892,  p.  27). 


THE   UNCERTAINTY  OF  THE  SIGNS  OF  DEATH.        47 

burned  for  two,  three,  four,  or  five  hours.  It  is  to  this  rapid 
liberation  of  carbonic  acid  that  the  well-sinkers  succumb  who 
pursue  their  trade  in  Paris  and  the  suburbs. 

We  likewise  placed  cages  of  birds  and  of  guinea-pigs  in 
the  graves.  The  birds  in  those  cages  which  we  let  down  to 
the  bottom  died  ;  those  in  the  cages  placed  nearer  the  sur- 
face were  in  a  state  of  apparent  death  when  they  were  drawn 
up.  When  placed  on  their  backs  in  the  open  hand,  they 
came  to  life  suddenly  and  flew  away. 

There  is,  then,  in  these  cases  a  state  of  anaesthesia  which 
is  dissipated  suddenly,  without  leaving  any  traces,  and 
which  can  be  compared  to  that  produced  by  nitrous  oxide. 
Dr.  Harmand  had  to  do  with  a  case  of  this  sort.  The  phe- 
nomena which  he  described  could  be  produced  by  immersing 
a  person  in  an  atmosphere  saturated  with  carbonic  acid,  but 
not  with  carbonic  oxide. 

Drunkenness-  may  also  produce  a  condition  of  apparent 
death.  M.  Bourneville  cites  the  case  of  an  old  woman  found 
in  the  street,  who  no  longer  breathed  or  gave  any  sign  of 
life.  She  was  conveyed  to  the  hospital.  The  rectal  tem- 
perature was  77°  F.  Energetic  treatment  restored  her  to  life. 
M.  Laborde  mentions  an  individual  picked  up  in  a  lifeless 
condition  at  the  gate  of  the  Bicetre.  He  was  carried  into 
the  hospital.  His  rectal  temperature  was  75°  F.  In  some 
little  time  he  revived,  and  eventually  recovered.  In  both 
these  cases  the  cause  was  drunkenness. 

AncEstliesia,  and  especially  chloroform  or  ether  anaesthesia, 
may  cause  a  state  of  apparent  death.  This  state  gives  way 
when  appropriate  treatment  is  quickly  administered.  But 
this  is  a  question  which  rather  concerns  surgery ;  I  shall 
not  go  farther  into  it,  except  to  say  that  in  fatal  cases  of 
chloroform  anaesthesia  the  palpebral  reflex  is  the  last  to 
disappear  (Boudin). 

In  some  years'  time.  Gentlemen,  it  will  be  possible  to 
make  a  more  complete  and  more  scientific  classification 
than  in  the  outline  I  have  just  sketched  to  you  ;  for  I  can 
only  make  a  rapid  review,  a  somewhat  dry  nomenclature,  at 
the  present  moment.  But  what  has  now  been  known  for 
some  years  about  the  toxic  principles  which  are  formed  in 


THE  SIGNS  OF  DEATH. 


the  human  body — you  may  call  them  toxines,  ptomaines, 
or  leucomaines — entitles  us  to  divide  them  into  two  groups, 
according  to  their  physiological  properties ;  we  are  able 
now  to  distinguish  them  either  as  convulsives,  analogous  in 
their  action  to  strychnine,  or  as  ancesthetics,  reminding  us  of 
chloroform.  The  experiments  which  I  performed  in  1878 
with  Boutmy  showed  that  ptomaines  extracted  from  the 
bodies  of  those  drowned,  and  injected  into  frogs,  produced 
phenomena  of  both  classes.* 

It  is  impossible  to  deny  that  in  individuals  whose  pro- 
cesses of  nutrition  are  slackened,  as  they  are  in  hysterical 
patients,  or  whose  nutrition  is  profoundly  altered,  as  it  is  in 
alcoholic  subjects,  toxic  substances  may  be  produced,  giving 
analogous  results.  But  in  the  present  state  of  our  know- 
ledge it  is  not  possible  to  affirm  anything  more. 

It  has  been  insisted  strongly,  in  reference  to  this  matter, 
that  in  certain  acute  diseases,  such  as  cholera,  plague,  or 
typhoid  fever,  there  may  be  prolonged  attacks  of  syncope, 
which  are  easy  to  confound  with  apparent  death  ;  M.  Dieu- 
lafoy's  thesis  was  devoted  to  this  subject.  It  seems  to  me 
that  there  need  be  no  fear  of  confounding  these  attacks 
of  syncope  with  apparent  death.  In  these  cases  the  myo- 
cardium is  altered ;  the  heart  stops  because  its  muscle  is 
affected  and  has  yielded:  it  seems  to  me  difficult  to  admit 
that  any  state  can  be  met  with  in  those  diseases  that  might 
be  mistaken  for  apparent  death. 

As  to  syncopal  attacks  from  which  persons  may  and  do 
revive,  they  are  not  usually  of  sufficient  duration  to  stand 
the  chance  of  being  mistaken  for  apparent  death. 

PREMATURE  BURIAL. 

There  is,  then,  such  a  thing  as  apparent  death  ;  that  is  to 
say,  certain  conditions  may  simulate  real  death.  It  is  im- 
possible to  say  how  long  such  a  condition  may  last,  and  we 
can  affirm  that  it  is  possible,  in  a  certain  number  of  cases,  to 

*  Brouardel  et  Boutmy,  '  D^veloppement  des  Alcaloides  cadaverique  , 
Ptomaines'  {Ann.  d^Hyg.^  1880).  '  Des  Ptomaines,  Reactif  propre  a  les 
distinguer  des  Alcaloides  v^gdtaux'  {Ann.  d'Hyg.,  1880).  'Conditions 
du  Developpement  des  Alcaloides'  {Ann.  d'Hyg.,  1881). 


PREMATURE  BURIAL.  49 

restore  to  life  persons  who  have  been  believed  to  be  quite 
dead. 

Having  said  so  much,  I  add  that  in  the  immense  majority 
of  cases  we  die  after  a  struggle,  by  suffocation,  by  bronchial 
over-secretion,  but  after  a  more  or  less  long  and  painful 
scene.     In  these  cases  death  does  not  raise  any  doubt. 

Allied  to  this  question  of  apparent  death,  which  has 
excited  men's  minds  ever  since  Winslow  raised  it,  thefe  is 
another  which  is  grafted  upon  it,  and  which  has  always 
occupied  public  attention.  Petitions  have  been  presented 
to  the  Chambers,  elaborate  reports  have  twice  been  issued, 
and  I  myself  am  entrusted  at  the  present  time  with  the 
preparation  of  a  third.  The  question  is  this :  Can  an  indi- 
vidual, after  being  buried  while  in  a  state  of  apparent  death, 
come  to  life  again  in  the  grave  ?  Except  Dr.  Roger's  case, 
which  I  have  narrated  already,  none  of  the  cases  reported 
as  such  are  very  conclusive.  The  newspapers  describe  them ; 
but  no  medical  man  has  been  present.  When  I  read  of 
such  a  case  in  the  newspaper,  I  make  an  inquiry  —  as 
Bouchut,  M.  Tourdes,  and  M.  Armaingaud  used  to  do  ;  I 
write  to  the  mayor  or  to  the  medical  officer  of  health,  and 
ask  him  if  the  facts  are  genuine.  The  reply  I  am  wont  to 
receive  is  that  the  story  is  quite  unknown  in  that  part  of  the 
country  whence  it  is  supposed  to  have  come,  or  that  the 
person  mentioned  is  not  dead  and  has  not  been  placed  in  a 
coffin. 

Nevertheless,  I  should  not  like  to  affirm  that  a  person  in 
the  state  of  apparent  death  could  not  be  buried.  If  he 
were  to  return  to  himself,  how  long  could  life  be  maintained 
in  the  coffin  ?  In  an  ordinary  coffin,  with  a  glass  lid,  a  dog 
lived  for  five  or  six  hours  ;  but  a  dog  occupies  much  less 
space  than  a  man  ;  the  latter,  after  being  once  shut  up  in 
his  coffin,  has  scarcely  3^  cubic  feet  of  air;  he  might  there- 
fore be  able  to  breathe  for  twenty  minutes.  I  do  not  wish 
anyone  to  pass  such  a  dreadful  twenty  minutes. 

This  calculation  is  based  on  the  average  respiratory 
activity ;  in  persons  whose  nutrition  is  conducted  more 
slowly  than  in  others,  such  as  the  hysterical  subjects  of 
whom  we  have  spoken,  survival  might  be  much  longer. 

4 


LECTURE  III. 

THE  SIGNS  OF  DEATH. 

Gentlemen, — We  come  now  to  the  study  of  the  signs  of 
death,  those  signs  which  will  enable  us  to  avoid  the  errors 
which  I  have  pointed  out  to  you  as  possible ;  how  can  they 
be  determined,  and  whose  duty  is  it  to  prove  their  existence  ? 

I  shall  divide  these  signs  into  two  classes :  those  which 
show  themselves  immediately  after  death,  and  those  which 
do  not  appear  for  some  hours  afterwards,  such  as  rigor 
mortis  and  putrefaction. 

Gentlemen,  every  author  who  has  taken  up  the  question 
has  endeavoured  to  bring  to  light  a  pathognomonic  sign 
which  shall  enable  us  to  certify  death  in  the  earliest  moment 
after  life  has  departed.  There  is  no  more  any  patho- 
gnomonic sign  to  determme  the  moment  of  death  than  there 
is  to  establish  the  diagnosis  of  typhoid  fever.  Just  as  in  the 
latter  it  is  a  combination  of  symptoms  observed  (headache, 
epistaxis,  fever,  diarrhoea,  rose  spots,  etc.)  which  make  the 
diagnosis  sure,  so  in  the  case  of  death  it  is  a  collection  of 
signs  which  gives  the  physician  absolute  certainty,  and  he 
alone  can  estimate  their  value.  Let  us  see  what  the  different 
signs  are,  so  that  we  may  examine  them  seriatim.  In  the 
first  hours  we  have  on\y  negative  signs,  we  notice  the  abolition 
of  the  bodily  functions  ;  intelligence  is  abolished  after  death, 
but  so  it  is  in  syncope. 

INSENSIBILITY. 

This  is  general  and  complete,  but  certain  hysterical  sub- 
jects, or  persons  in  whom  there  is  general  anaesthesia,  pre- 
sent the  same  phenomena.     Here,  then,  is  one  cause  of  error, 


INSENSIBILITY.  51 


which  is  all  the  greater  inasmuch  as  Charcot  has  shown  that 
these  anaesthetic  individuals  may  be  pricked  with  pins  with- 
out a  drop  of  blood  escaping,  unless  a  large  vein  be  pierced. 

Josat  invented  a  pair  of  forceps  with  claws,  with  which  he 
proposed  to  pinch  the  nipples  of  persons  whose  death  has 
to  be  ascertained.  Josat  obtained  the  first  prize  of  the 
Academy,  but  Briquet,  repeating  the  same  tests  on  the 
hysterical  subjects  under  his  care,  proved  that  they  did  not 
react  under  Josat's  forceps  any  more  than  the  dead. 

Analogous  experiments  have  been  made  on  all  the  senses. 

Hearing. — It  has  been  the  custom  for  women  to  be  placed 
around  the  dead  man's  bed,  to  cry  and  howl,  with  the  object 
of  waking  the  dead  if  he  were  so  only  in  appearance.  This 
custom,  which  dates  from  the  remotest  antiquity,  is  still 
practised  in  some  of  the  departments  of  the  South  of  France. 

Smell. — By  passing  beneath  the  nose  of  the  body  the  vilest 
and  strongest  perfumes.  (In  this  respect  allow  me  to  remind 
you  that  a  small  drop  of  ether,  thrown  high  enough  up  into  the 
nostrils,  rouses  a  person  from  tolerably  profound  syncope.) 

The  reactions  of  the  eye  have  been  closely  studied.  Even 
quite  recently  a  learned  man  discoursed  at  the  Institute 
about  a  certain  sign  of  death,  viz.,  the  immediate  lessening 
of  tension  of  the  globe  of  the  eye  at  the  moment  of  death, 
due  to  the  cessation  of  circulation  and  emptying  of  the 
vessels.  It  proves  that  the  heart  is  not  beating,  but  not 
that  the  person  is  dead.  The  iris  undergoes  modifications. 
During  the  death-struggle,  and  at  the  moment  of  death,  the 
pupil  dilates,  even  so  as  almost  to  disappear  completely, 
then  it  gradually  returns  to  its  normal  midway  position  ;  and 
as  the  eye  loses  more  and  more  of  its  tension,  the  iris  is 
thrown  into  folds.  Bouchut,  who  has  taken  great  interest 
in  these  questions,*  has  observed  that  atropine  and  eserine 
have  no  effect  after  death.  Too  much  importance  must  not 
be  attached  to  these  signs ;  if  the  ocular  tension  persist,  it 
is  not  necessarily  because  life  remains.  For  in  the  drowned, 
owing  to  the  imbibition  and  absorption  of  water,  tension  is 
often  increased,  the  eyeball  being  harder  than  in  the  normal 
condition. 

*  Bouchut,  '  Les  Signes  de  la  Mort  et  les  Moyens  de  prevenir  les 
Inhumations  prematur^es.'     3rd  edition.     Paris,  1883. 


52 


THE  SIGNS  OF  DEATH. 


A  method  of  recognizing  death  has  been  borrowed  from 
the  saleswomen  at  the  markets.  When  these  women  buy  a 
fowl  or  a  fish,  they  look  at  its  eye  ;  it  shows  a  speck  on  the 
sclerotic  which  gives  the  eye  the  appearance  of  parchment, 
and  this  is  all  the  more  plainly  visible  the  longer  the  time 
that  has  elapsed  since  death.  A  man  dies  with  his  eyes 
half  shut,  and  an  attendant  closes  them  completely.  If  the 
lids  had  remained  open,  you  would  see  that  the  conjunctiva- 
and  sclerotic  presented  a  very  characteristic  brown  hue. 
M.  Larcher,*  of  Passy,  has  insisted  strongly  on  this  sign. 

Allow  me  to  say  a  word  or  two  about  a  plan  that  was 
urged  on  a  particular  occasion,  and  which  made  some  stir 
in  forensic  medicine.  It  was  suggested  that  in  persons 
dying  suddenly  the  eye  preserved  the  impression  of  objects 
which  were  in  front  of  it.  Photographs  of  the  retina  of  a 
person  supposed  to  have  been  murdered  were  shown  to  the 
Society  of  Legal  Medicine.  It  is  said  that  these  photo- 
graphs reproduced  the  figures  of  a  man  and  dog  in  the  act 
of  springing  and  making  the  attack  to  which  the  individual 
had  succumbed.f  These  images,  which  were  said  to  be 
so  clear,  were  really  extraordinarily  vague,  and  yet  in  his 
report,  M.  Vernois  was  quite  positive  about  them.  Kiihne 
of  Heidelberg  has  repeated  the  experiment.  I  have  seen 
some  of  his  photographs,  and  some  of  them  are  very  distinct. 
He  placed  a  grating  in  front  of  a  rabbit,  then  killed  the 
animal  rapidly  and  removed  its  eye,  exposed  the  retina  and 
photographed  it.  In  the  print  the  transverse  and  vertical  bars 
of  the  grating  may  be  recognized.  He  has  endeavoured  also 
to  reproduce  a  fence  and  a  chair  ;  but  even  when  set  in  the 
full  sunshine  these  objects  gave  only  very  indistinct  images. 
Many  obstacles  besides  stand  in  the  way  of  these  experi- 
mental results  ever  having  a  practical  use  in  forensic  medi- 
cine; the  animal  must,  as  a  matter  of  fact,  be  killed  rapidly, 
and  the  retina  must  be  photographed  immediately  after 
death.    These  conditions  are  hardly  to  be  realized  in  forensic 

*  Larcher,  '  De  la  Rigidite  cadaverique  et  d'un  nouveau  Signe  de  le 
Mort  (Tache  scleroticale)'  {Amz.  d'Hyg.,  1869,  tome  xxxi.,  p.  468). 

f  Vernois,  '  Application  de  la  Photographic  a  la  Medecine  legale  : 
Rapport  sur  une  communication  de  M.  le  Dr.  Bourion'  {An7J.  d'Hyg., 
1870,  tome  xxxiii.,  p.  239). 


MOTILITY.  53 

medicine ;  and  though  these  results  in  animals  may  have  some 
little  weight,  we  cannot  admit  that  we  should  find,  twenty- 
four  or  forty-eight  hours  after  death,  any  copy  on  the  retina 
of  a  murdered  man  of  the  last  scene  of  the  fatal  drama. 

MOTILITY. 

The  immohility  of  death  has  been  considered  a  classi- 
cal sign ;  and  the  same  importance  has  been  attributed 
to  the  falling  of  the  lower  jaw,  which  immediately  follows 
the  moment  of  death,  and  the  occurrence  of  which  is  pre- 
vented before  rigor  mortis  sets  in  b}'  the  application  of  a 
bandage  round  the  head.  This  sign  is  not  constant ;  death 
may  take  place  with  the  mouth  closed  in  tetanus,  poisoning 
by  strychnine  and  hysteria. 

A  young  man  called  one  day  at  a  chemist's,  whose  identity, 
happily  for  him,  has  never  been  traced,  to  ask  for  some 
strychnine  to  kill  his  cat.  The  chemist  supplied  him  with 
the  strychnine ;  but  the  young  man  changed  his  mind  when 
he  reached  home,  and  no  longer  wished  to  kill  the  cat.  Before 
shutting  up  the  strychnine  which  the  chemist  had  given  him 
in  a  drawer^he  thought  he  would  like  to  see  what  the  powder 
tasted  like  ;  so  he  wetted  his  finger,  dipped  it  in  the  powder, 
and  licked  it ;  he  died  in  the  midst  of  horrible  convulsions, 
with  the  jaws  closed  and  the  biceps  and  psoas  muscles 
globular  and  contracted. 

Gentlemen,  when  a  person  dies  he  usually  falls  flat  on  the 
ground,  though  not  invariably  ;  the  exceptions  have  nearly  all 
been  observed  on  the  field  of  battle.  When  the  cervical 
part  of  the  spinal  cord  is  injured  a  little  below  the  bulb,  the 
individual  struck  may  preserve  his  attitude,  so  as  to  be,  as  it 
were,  transformed  into  a  statue,  if,  at  the  moment  of  being 
struck,  he  is  in  equilibrium.  I  can  give  you  as  an  example 
the  case  of  an  English  Colonel  charging  at  Inkermann  at  the 
head  of  his  regiment,  sword  in  hand.  His  head  was  carried 
away  by  a  cannon-ball ;  nevertheless  he  continued  the  act  of 
charging,  firmly  seated  on  his  horse,  which  bore  him  into 
camp  with  the  rest  of  the  regiment.  The  fact  was  published 
at  the  time,  but  some  doubts  were  raised  as  to  its  authen- 
ticity, whereupon   one  of  the  military  surgeons  who  was 


54  THE  SIGNS  OF  DEATH. 

present  at  the  battle  of  the  Alma  produced  the  photograph 
of  a  Turk  who  was  killed  when  he  was  in  the  act  of  saying 
his  prayers,  and  who  had  been  found  on  his  knees  with  his 
hands  joined  together,  fixed  in  the  position  in  which  he  was 
struck. 

During  the  American  War  of  Secession,  a  trooper  from 
the  Potomac  was  surprised  at  the  moment  of  mounting  his 
horse  ;  he  was  hit  by  a  ball,  which  injured  the  spinal  cord 
in  the  neck  ;  he  remained  upright  and  motionless  in  the 
position  in  which  he  was  struck,  with  one  foot  in  the 
stirrup  and  his  hand  on  the  mane  of  his  horse,  which  had 
not  stirred.     He  was  photographed  in  this  attitude. 

A  French  soldier  was  found,  during  the  war  of  1870, 
sitting  on  the  edge  of  a  stream  drinking  out  of  his  can. 
This  soldier  had  been  beheaded  by  a  cannon-ball ;  the  lower 
jaw  was  disarticulated  and  hung  down  on  his  neck. 

Wounds  of  the  cervical  cord  may  therefore  induce  com- 
plete rigidity  of  the  corpse,  and  stability  in  the  position 
which  the  wounded  man  occupied  at  the  moment  of  his 
death. 

The  same  fact  happened  at  Bazeilles,  but  from  a  different 
lesion.  A  Prussian  foot-soldier  was  photographed  while 
about  to  shoot,  his  gun  being  supported  on  an  iron  bar. 
This  soldier  had  a  large  wound  in  his  belly,  but  the  spinal 
cord  was  untouched.  He  had  doubtless  died  by  inhibition ; 
it  is  the  only  instance  of  the  kind  that  I  know. 

We  ought  to  collect  all  these  cases,  for  the}^  may  have 
their  application  in  forensic  medicine.* 

It  is  stated  by  some  old  authors  that  an  individual 
sometimes  dies  wearing  on  his  face  the  expression  of  the 
sentiments  he  felt  at  the  moment  of  death.  Fodere  has 
gone  much  farther.  He  has  attempted  to  distinguish  between 
suicide  and  murder  by  means  of  this  test.  I  have  often 
wished  to  verify  the  fact.  Gentlemen,  but  I  have  never  been 
able  to  find  the  slightest  proof  of  such  a  thing.  There 
probably  are  psychical  phenomena  in  these  cases,  but  they 

*  '  The  Soldier  in  Battle,'  by  Frank  Wilkeson,  has  an  interesting 
chapter,  '  How  Men  die  in  Battle,'  which  bears  closely  on  this  subject. — 
Translator. 


MOTILITY.  55 


are  on  the  part  of  the  medical  man,  not  of  the  victim. 
This  is  especially  true  when  an  execution  takes  place. 
Owing  to  the  circumstances  of  the  case,  the  local  sur- 
roundings, the  displacement  of  property,  the  blood  spilt, 
and  the  attitude  of  the  victim,  a  singular  sensation  is  aroused 
which  impresses  the  event  on  the  mind  of  the  physician. 

I  have  spoken  to  you  of  the  Pranzini  case  {vide  p.  3).  When 
I  saw  the  victims,  it  seemed  to  me  that  the  countenance 
of  Marie  Regnault  had  an  expression  of  indescribable  horror; 
she  simply  had  her  eyes  open,  and  their  fixity  was  most 
impressive.  It  is  necessary  to  warn  you.  Gentlemen,  against 
relying  too  much  on  this  first  impression  when  you  are 
summoned  to  make  a  medico-legal  examination.  In  such 
circumstances  have  a  photograph  taken  of  the  victim,  for 
by  photography  only  will  you  be  able  to  get  the  magistrate 
and  jurymen  to  share  your  opinion,  and  it  will  enable  you 
to  review  your  first  ideas  coolly.  Photography  has  now 
become  a  ver}^  commonplace  art.  Get  a  photographer  to 
accompany  you  in  your  proceedings  whenever  you  can.  A 
photograph  gives  the  exact  appearance  of  a  wound  better 
than  all  technical  descriptions. 

Muscular  immobility  is  attended  with  relaxation  of  the 
sphincters.  Muscular  contractility  lasts  for  some  time  yet ; 
then  it  disappears,  and  cannot  be  aroused  again  even  by 
means  of  electricity.  When  Ruhmkorff  invented  his  coil,  it 
was  thought  that  this  might  perhaps  serve  to  furnish  a 
certain  sign  of  death  ;  the  Senate  was  flooded  with  petitions 
that  experiments  should  be  instituted  ;  people  even  went  so 
far  as  to  demand  that  the  priests  might  keep  a  Ruhmkorff's 
coil  in  every  church,  and  test  the  muscular  contractility  of 
every  corpse  before  proceeding  with  the  funeral  ceremonies. 
These  experiments  would  have  serious  inconveniences,  the 
least  of  which  would  be  the  ignorance  of  the  priests  charged 
to  carry  them  out,  and  I  do  not  want  to  insist  on  the 
childish  and  uncertain  character  of  the  test. 

Dr.  Collongues*  attaches  great  importance  to  '  dynamos- 
copy  ';  he  affirms  that,  when  you  put  into  your  ear  the  finger 
of  a  living  person,  two  noises  can  be  heard  distinctly,  two 
*  Collongues,  '  Traite  de  Dynamoscopie.'     Paris,  1862. 


56  THE  SIGNS  OF  DEATH. 

slight    rolling   sounds    produced    by   the  muscular  system. 
When  these  sounds  disappear,  the  individual  is  dead. 

Gentlemen,  leaving  aside  the  fact  that  it  is  not  very 
pleasant  to  introduce  a  dead  person's  finger  into  one's 
auditory  passage,  there  are  two  sources  of  error  :  (i)  When 
you  put  a  living  finger  into  your  ear,  you  can  hear  a  number 
of  sounds  which  I  would  compare  to  the  humming  or 
buzzing  which  is  produced  by  holding  a  shell  to  the  auditory 
meatus;  (2)  when  the  finger  is  dead,  these  noises  maybe 
almost  the  same  if  the  finger  is  not  placed  in  the  right 
position. 

RESPIRATION. 

Abolition  of  respiration  is  the  most  untrustworthy  of  all 
the  signs  which  have  been  invoked.  You  know  the  test  of 
placing  a  mirror  before  the  lips  of  the  corpse  ;  perhaps  you 
do  not  know  that  of  the  glass  of  water,  full  to  the  brim, 
placed  on  the  hollow  of  the  epigastrium,  which  was  extolled 
by  Winslow.  He  held  that  if  the  water  ran  over,  the  indi- 
vidual was  not  dead. 

Winslow  either  forgot  or  did  not  know  that  rhythmical 
contractions  of  the  diaphragm  persist  after  death  ;  these 
may  provoke  evacuation  of  gases,  and  even  hiccough,  as  a 
result  of  which  the  mirror  becomes  soiled  and  the  glass 
upset. 

CIRCULATION. 

I  come  now,  Gentlemen,  to  the  two  signs  or  the 
pair  of  signs  which  are  of  chief  importance,  i.e.,  the 
cessation  of  circulation  and  the  temperature  phenomena 
which  ensue  upon  death.  In  former  times  one  used  to  feel 
the  pulse  of  the  dying  man,  and  when  the  beat  of  the  radial 
artery  could  no  longer  be  felt,  it  used  to  be  said,  '  It  is  all 
over;  the  patient  is  dead.'  Bouchut,*  who  has  studied  all 
these  questions  with  great  care,  has  rightly  said  that  one 
must  not  be  satisfied  with  feeling  the  pulse,  but  must  go 

*  Bouchut,  '  Les  Signes  de  la  Mort  et  les  Moyens  de  pr^venir  les 
Inhumations  prematurees.'     3rd  edition.     Paris,  1883. 


CIRCULATION.  57 


higher,  and  consult  the  heart  also.  In  a  memoir  published 
by  him,  and  submitted  to  the  Academy  of  Science,  he  states 
that  an  interruption  of  the  action  of  the  heart  lasting  for 
two  minutes  was  sufficient  to  render  the  diagnosis  of  death 
certain.  Andral,  who  was  appointed  to  report  on  Bouchut's 
memoir,  believed  that  this  interruption  should  be  prolonged 
for  tive  minutes.  Later  on  he  was  obliged  to  acknowledge 
that  even  this  length  of  time  was  inadequate,  since  in  the 
interval  he  had  met  with  a  woman  who  returned  to  life  some 
hours  after  the  action  of  the  heart  had  ceased  to  be  per- 
ceptible ;  it  is  true  that  a  few  contractions  could  be  perceived 
from  time  to  time,  but  they  vanished,  to  reappear  later. 

Bouchut  thinks  the  heart  should  be  listened  to  for  half  an 
hour.  There  are  at  least  two  sources  of  error  there.  Gentle- 
men ;  you  cannot  listen  to  a  heart  for  half  an  hour  con- 
tinuously. Try  to  do  so  ;  in  five  or  six  minutes  you  will 
hear  buzzings  and  murmurs  of  all  sorts,  and  at  last  you  will 
hear  the  beating  of  your  own  heart.  A  second  source  of 
error  is  as  follows :  When  an  animal  is  dying,  and  you 
practise  auscultation,  you  hear  very  plainly  the  two  sounds 
of  the  heart,  then  only  one  sound,  which  presently  dis- 
appears also.  If  the  animal  is  opened,  the  heart  is  found 
still  beating.  Therefore  it  is  essential  that  the  heart 
should  beat  with  a  certain  degree  of  energy  in  order  that 
its  beats  should  be  heard.  And  lastly,  without  suspecting 
the  talents  of  my  fellow-practitioners,  it  is  evident  that 
certain  physicians  will  be  able  to  perceive  the  beats  of  the 
heart  after  others  can  no  longer  do  so.  Sharpness  of  hear- 
ing is  not  the  same  in  everybody  ;  and  when  auscultation 
is  in  question,  the  education  of  the  ear  is  a  very  important 
factor.  It  is  certain  that  all  of  us  require  to  repeat  our 
apprenticeship  in  auscultation  when  we  have  not  been  en- 
gaged in  practice  for  a  time — when  we  return  from  a  holiday, 
for  instance.  It  is  a  question  of  the  force  of  daily  habit.  I 
am/  sure  that  none  of  us  has  an  auditory  nerve  as  delicate 
d.nd  susceptible  as  that  of  any  clinical  professor  at  Paris. 
We  must  not  pay  much  heed  to  those  experiments,  which 
may  be  all  very  well  as  tests  in  the  laboratory  or  in  the 
hospital,  but  are  not  always  feasible  in  the  course  of  practice. 


58  THE  SIGNS  OF  DEATH. 

Moreover,  the  principle  itself  is  merel}'  an  assumption ;  for 
we  know  that  an  individual  whose  heart  no  longer  beats 
may  survive  {vide  supra  :  the  two  men  hanged  at  Boston  and 
at  Buda-Pesth).  The  absence  of  the  beats  of  the  heart  may- 
be considered  as  a  sign  of  apparent  death,  but  not  of  real 
death. 

You  know  the  following  experiment  as  it  is  performed  in 
the  laboratory  or  in  the  course  of  lectures  ;  M.  Middeldorf 
has  ventured  to  extol  it  as  a  certain  sign  of  death.  A  needle 
with  a  small  flag  at  one  end  is  thrust  into  an  animal's  heart; 
this  flag  waves  as  long  as  the  heart  beats.  M.  Middeldorf 
wished  to  introduce  this  experiment  into  practice,  and 
called  it  the  '  akidopeirastic '  method,  and  he  devised  for 
employment  in  this  way  needles  4  inches  long,  which  the 
physician  was  to  thrust  into  the  heart  of  the  person  whose 
death  he  had  to  verify.  This  method  seems  to  me  to  be 
scarcely  applicable  in  family  practice ;  objections  would  be 
raised  and  resistance  offered,  which  seems  to  me  to  be  very 
natural. 

While  still  making  use  of  the  stoppage  of  circulation, 
other  authors  have  proposed  section  of  the  temporal  artery. 
If  the  heart  were  beating,  this  section  would  be  followed  by 
a  flow  of  blood  ;  there  would  be  none  in  the  contrary  case. 
I  think  it  would  be  useless  to  repeat  before  you  the  dis- 
cussion already  set  forth  on  the  subject  of  the  movements  of 
the  heart. 

Phlebotomy  was  formerly  considered  the  classical  procedure 
to  determine  the  reality  of  death  ;  the  family,  and  sometimes 
the  deceased  himself,  have  expressed  a  wish  to  have  a  vein 
opened,  in  order  to  make  sure  that  no  blood  would  flow. 

Gentlemen,  venesection  of  a  person  just  dead  yields  no 
blood.  But  if,  after  opening  the  vein,  you  do  not  take  the 
precaution  of  fastening  a  firm  bandage  over  the  wound,  the 
vein  will  yield  some  blood  in  the  course  of  a  few  hours. 

The  explanation  of  this  apparently  abnormal  fact  is  very 
simple.  When  the  individual  dies,  chemical  processes  con- 
tinue ;  fermentation  develops  gases  in  the  intestines,  which, 
if  the  temperature  is  high,  may  acquire  in  twenty-four  hours 
a  tension  in  the  abdomen  of  an  atmosphere  and  a  half. 


CIRCULATION.  59 


Under  the  influence  of  this  tension  the  diaphragm  is  pushed 
up  as  far  as  the  third  rib,  and  the  blood  in  the  heart,  great 
vessels,  and  lungs  is  driven  towards  the  periphery  in  the 
veins.  It  is  an  actual  posthumous  circulation.  At  the 
moment  of  death  the  skin  is  white.  Putrefaction  begins ; 
the  outline  of  the  veins  may  be  seen  in  blue  under  the  skin, 
and  if  venesection  is  performed  blood  escapes,  sometimes  in 
abundance,  though  it  will  not  coagulate.  That  is  a  very 
important  fact,  and  in  the  Middle  Ages  a  singular  interpreta- 
tion was  drawn  from  it. 

You  know  what  was  called  '  the  judgment  of  God  '  ? 
When  a  corpse  was  found  near  a  village,  and  it  was  im- 
possible to  detect  the  murderer,  the  inhabitants  were  made 
to  file  before  the  corpse ;  if  blood  and  gas  escaped  from  the 
wounds,  the  person  who  stood  before  the  body  at  that 
moment  was  arrested  ;  that  man,  it  was  said,  was  the 
assassin,  because  the  corpse  revolted  at  the  sight  of  him. 
This  custom  prevailed  until  the  reign  of  Charles  V.,  who 
instituted  the  first  medical  jurists. 

Other  difficulties  also  crop  up  with  respect  to  phlebotomy. 
If  bleeding  is  performed  on  anyone  who  has  just  died,  the 
blood  ought  not  to  coagulate,  it  is  said.  When  blood  flows 
from  a  wound  made  on  a  person  who  has  just  expired,  it 
may  coagulate,  but  the  clot  thus  obtained  resembles  currant- 
jelly  ;  it  will  be  treacly,  and  flow  as  a  liquid  on  the  scalpel. 
Between  a  clot  like  this  and  a  firm,  well-cupped  coagulum 
obtained  from  a  case  of  pneumonia,  there  is  an  infinity  of 
degrees,  according  to  the  greater  or  less  consistence  of  the 
meshes  formed  by  the  network  of  fibrin.  When  you  perform 
phlebotomy  thus  at  the  request  of  the  family  or  of  the 
deceased  himself,  who  thought  that  he  would  in  this  way 
elude  the  danger  of  being  buried  alive,  always  place  a  tight 
ligature  on  the  arm  after  opening  the  vein,  so  that  the  blood 
expelled  by  putrefaction  may  not  escape  afterwards. 

Ligature  of  the  finger  has  been  considered  by  some  to 
furnish  a  certain  sign  of  death.  If  the  individual  is  alive, 
the  finger  becomes  blue;  if  he  is  dead,  it  does  not  alter  its 
colour.  This  sign  indicates  whether  circulation  persists  or 
not. 


6o  THE  SIGNS  OF  DEATH. 

The  same  applies  to  cupping  and  leeches  as  to  bleeding. 
Leeches  may  suck  blood  when  the  posthumous  circulation, 
of  which  I  have  just  been  speaking,  is  established.  Here 
is  an  example:  M.  Tourdes  pronounced  that  a  certain  person 
was  dead ;  however,  leeches  were  applied  ;  the  leeches  took, 
and  the  next  day,  when  M.  Tourdes  returned,  three  leeches 
still  held  and  had  drawn  a  little  blood. 

These  are  delicate  tests,  subject  to  many  fallacies  ;  pre- 
cisely for  this  reason  I  do  not  think  they  deserve  the 
semeiotic  value  which  has  been  attributed  to  them. 

Decoloration  of  the  Retina,  due  to  the  absence  of  circula- 
tion, is  a  very  dihicult  sign  to  get  evidence  of  in  private 
practice. 

CADAVERIC  SUGGILLATIONS. 

These  are  a  consequence  of  the  abolition  of  circulation ; 
I  do  not  hesitate  to  attach  great  importance  to  them,  with- 
out, however,  going  so  far  as  to  say  that  they  constitute  an 
infallible  sign.  When  we  examine  a  body,  we  find  in  the 
dependent  parts  that  the  skin  is  covered  with  violet  patches 
which  have  been  called  cadaveric  suggillations  or  lividity. 

To  what  can  these  patches  be  attributed  ?  When  they 
are  cut  through,  it  is  seen  that  the  little  capillary  vessels  of 
the  skin  are  gorged  with  livid  blood  ;  if,  at  the  end  of  four 
or  five  hours,  a  fresh  section  is  made,  it  will  be  evident,  not 
only  that  the  veins  contain  blood,  but  also  that  the  colour- 
ing matter  of  the  blood  has  exuded  into  the  tissues  around. 

Could  these  suggillations  be  confounded  with  any  other 
lesions  ?  When  there  is  merely  venous  congestion,  it  is 
very  difficult  to  mistake  it  for  an  ecchymosis.  Ecchymosis 
is  due,  in  fact,  to  an  extravasation  of  blood ;  but  even  when 
in  a  suggillation  there  is  some  effusion  of  colouring  matter 
of  the  blood,  you  must  be  but  very  little  acquainted  with 
these  phenomena  to  mistake  it  for  an  ecchymosis.  When 
blood  has  escaped,  the  serum,  stained  by  the  colouring 
matter  which  has  left  the  corpuscles,  is  absorbed  by  and 
colours  the  neighbouring  tissues. 

In    the  instants  which    immediately  follow   death,   these 


SUGGILLATIONS.  ,  6i 


suggillations  have  a  great  value ;  w^hen  they  are  recent,  they 
may  be  displaced  by  turning  the  body  over.  The  distri- 
bution of  these  patches  of  lividity  indicates  the  position  the 
body  has  occupied  for  some  hours.  But  if  we  turn  the  body 
over,  the  suggillations  alter  their  situation;  they  always  show 
themselves  in  dependent  parts.  If  death  is  not  recent,  and 
the  tissues  are  stained  by  the  colouring  matter  of  the  blood, 
the  suggillations  no  longer  shift  their  place. 

Suggillations  are  constant.  In  an  interesting  work  pub- 
lished by  Dr.  Mollaud,  an  inspector  of  verification  of  death 
in  Paris,  he  has  summarized  15,146  cases  observed  by  him  ; 
suggillations  were  not  absent  once. 

Nevertheless,  difficulties  present  themselves  here  also  ;  in 
the  first  place,  it  is  not  always  easy  to  determine  the  exist- 
ence of  lividity ;  when  there  has  been  abundant  haemorrhage 
there  may  be  none.  M.  Molland  affirms  that  he  has  seen 
them  in  women  who  have  died  of  post-partum  haemorrhage, 
but  in  these  cases  they  were  not  well  marked.  M.  Devergie 
is  of  the  same  opinion.  It  is  therefore  a  matter  requiring 
skill  to  estimate. 

The  patches  of  lividity  do  not  always  appear  at  the  same 
moment ;  in  persons  who  have  died  of  haemorrhage  they 
appear  late,  and  are  only  slight ;  they  show  themselves  five 
or  six  hours  after  death,  when  the  debatable  point  is  already 
settled,  and  the  proof  of  death  is  no  longer  wanting. 

On  the  other  hand,  they  may  appear  before  death  in 
cholera,  ursemia,  and  asphyxia.  In  persons  attacked  with 
cholera,  for  example,  the  peripheral  circulation  has  ceased. 
Magendie  was  unable  to  withdraw  a  single  drop  of  blood  from 
the  radial  artery  of  a  cholera  patient  who  lived  for  several 
hours  longer.  Lividity  which  appears  before  death  is  due 
to  stasis  of  blood,  i.e.,  to  gravitation,  not  to  an  alteration  of 
the  corpuscles. 

In  spite  of  these  reservations,  the  presence  of  suggillations 
is  an  important  sign. 


62  THE  SIGNS  OF  DEATH. 


TEMPERATURE  POST-MORTEM. 

I  come  now  to  the  phenomena  of  heat  which  ensue  after 
death.  The  evidence  afforded  by  the  temperature  is  a  sign 
of  great  importance  and  value.  It  has  been  much  studied 
both  in  France  and  abroad,  and  has  been  taken  up  again 
within  the  last  few  years  by  M.  Bourneville,  who  has  already 
written  much  on  the  subject. 

As  everyone  knows,  when  a  person  dies  his  body  becomes 
cold.  Nevertheless,  De  Haen  had  already  remarked  that 
in  the  moment  of  death  there  was  sometimes  a  rise  of 
temperature.  In  certain  infective  diseases,  such  as  small- 
pox and  cholera,  the  rectal  temperature  may  rise  from 
3^°  to  7°  F.  This  rise  of  temperature  proves  that  chemical 
activity  lasts  after  life  has  departed  ;  then,  as  a  sequel  to 
the  rise,  there  is  a  lowering  of  temperature.  I  do  not  in- 
sist on  the  chemical  theories  which  have  been  formulated 
to  explain  these  phenomena  ;  they  are  of  no  consequence. 
Taylor  and  Wilks,  in  England,  have  tried  to  find  by  obser- 
vation of  the  laws  of  cooling  some  certain  sign  of  death.* 
They  noticed  that  six  or  eight  hours  after  death  the  tem- 
perature varies  from  6o°  to  8o°  F.,  and  that  twelve  hours 
after  it  varies  from  56°  to  79°  F. 

Gentlemen,  when  a  man  dies,  he  may  do  so  under  one  of 
two  conditions  :  either  he  dies  at  home  or  he  dies  in  the 
hospital.  If  he  dies  in  his  bed,  as  soon  as  he  has  breathed 
his  last  the  bed-coverings  are  drawn  over  him,  candles  are 
lighted  by  the  side  of  his  bed,  and  a  fire  is  kept  up  for  the 
sake  of  ventilation.  He  remains  in  the  bed  wherein  he 
died  ;  the  mattress,  pillows  and  coverings  preserve  the  heat 
for  a  longer  or  shorter  period  of  time,  and  the  cooling  of 
the  body  is  reduced  to  a  minimum. 

At  the  hospital,  on  the  contrary,  the  dead  man  is  removed 
at  the  end  of  an  hour;  he  is  enveloped  in  a  shroud,  and  his 
body  is  laid  on  an  iron  table  or  marble  slab  in  the  dead- 
house  ;  the  rapidity  of  cooling  is  at  its  maximtim.  Between 
these  two  sets  of  conditions  there  is  complete   opposition. 

*  Taylor  and  Wilks,  '  Guy's  Hospital  Reports,'  3rd  series,  pp.  180-183. 


TEMPERATURE  'POST-MORTEM.'  63 

It  is  necessary  also  to  take  into  account  a  large  number  of 
circumstances  which  Taylor  and  Wilks  have  examined. 

ist.  The  external  temperature  ;  the  higher  this  is,  the 
slower  is  the  cooling,  which  thus  becomes  extremely 
variable. 

2nd.  The  disease  which  caused  death;  if  it  has  been  of 
long  duration,  cooling  is  slow  ;  if  death  was  due  to  haemor- 
rhage, cooling  will  be  rapid  ;  if  it  was  from  an  infective  disease 
(cholera,  tetanus,  small-pox)  there  will  be  an  initial  rise  of 
temperature. 

When  Alvarenga*  published  his  thermometric  observa- 
tions, he  drew  a  curve — a  somewhat  diagrammatic  one — of 
these  variations.  Wunderlicht  attributed  the  post-mortem 
rise  of  temperature  in  zymotic  diseases  to  rigor  mortis ;  he 
thinks  that  there  are  produced  at  this  time  thermo-chemical 
phenomena  identical  with  those  which  accompany  muscular 
contraction.     It  is  useless  to  discuss  this  question  now. 

In  1872  M.  Bournevillej  found  in  a  person  who  was  picked 
up  in  the  street  one  evening,  and  carried  to  the  hospital,  a 
temperature  of  Sig^"  F.  It  was  11  o'clock  at  night.  The 
man  was  kept  warm,  and  at  i  ajn.  the  rectal  temperature 
was  8^°  F.  He  died  at  8  a.m.  ;  five  minutes  after  death  the 
thermometer  rose  suddenly  to  99°  F.  This  man  was  not 
in  a  state  of  drunkenness. 

Thus,  there  are  persons  who,  from  drunkenness  or  from 
some  other  cause,  have  their  peripheral  circulation  impeded 
or  abolished  ;  when  these  persons  die,  the  spasm  which 
hindered  their  circulation  gives  way,  and  the  temperature 
rises  again.  This  fact  distinctly  depreciates  the  value  of 
the  sign. 

In  1878  Dr.  Guillemot§  made  a  study  of  the  same  facts  in 
an  excellent  thesis  which  has  not  as  yet  had  very  practical 
results.  He  proved  that  the  axillary  and  rectal  tempera- 
tures did  not  take  the  same  course  :  the  axillary  tempera- 
ture, which  may  be  regarded  as  an  index  of  the  external  or 

*  Alvarenga,  '  Precis  de  la  Thermometrie  gen^rale,'  1871,  p.  129. 
t  Wunderlich,  Archiv.  der  Heilkunde.,  tome  ii.,  p.  547. 
%  Bourneville,  Gazette  des  Hopitaux,  1872,  p.  32. 
§  Guillemot,  'These  de  1878.' 


64  THE  SIGNS  OF  DEATH. 

surface  temperature,  falls,  while  the  rectal  or  central 
temperature  remains  the  same,  or  at  any  rate  falls  but 
slowly  ;  at  the  end  of  some  hours  there  is  a  tendency  to 
equalization,  and  Guillemot  has  found  that  it  was  nearly 
complete  at  the  end  of  thirty  hours. 

We  are  all  familiar  with  Marey's  paradox.  A  person 
placed  between  two  others  gives  one  of  his  hands  to  each, 
who  may  disagree  about  the  temperature  of  the  hands  they 
hold.  One  of  these  two  persons  finds  the  hand  very  warm  ; 
the  other  one  finds  it  cold.  Which  is  the  one  who  feels  it 
cold  ?  It  is  the  warm  hand  which  is  chilled,  and  the  cold 
one  is  warmed.  After  death  the  periphery  of  the  body 
becomes  cool,  and  the  cooling  is  most  perceptible  in  the 
axilla.  When,  therefore,  owing  to  the  tension  of  the  gas 
which  forms  in  the  abdomen,  the  blood  is  driven  towards 
the  periphery,  this  part  gets  a  little  warmer;  as  I  have  just 
told  you,  Guillemot  assures  us  that  in  thirty  hours  equili- 
brium is  established  between  the  temperature  of  the  rectum 
and  that  of  the  periphery  ;  I  do  not  of  course  speak  here 
of  the  case  of  corpses  exposed  to  the  air  out  of  doors. 

On  October  28,  1893.  M.  Bourneville  stated,  and  published 
with  a  series  of  illustrative  cases,  that  the  rectal  temperature 
was  lower  than  that  of  the  surface  at  the  end  of  twelve  or 
fourteen  hours.  These  are  hospital  observations,  extremely 
interesting  and  necessary,  but  which  require,  in  order  to 
obtain  their  full  value,  to  be  compared  with  observations 
made  elsewhere  than  in  the  hospitals.  It  would  be  necessary 
to  take  another  series  of  persons  who  die  in  their  own  beds  ; 
if  this  second  series  gave  the  same  results  as  the  first,  a 
certain  sign  of  death  would  be  invented.  I  am  well  aware 
that  there  are  in  practice  certain  material  difficulties  which 
would  have  to  be  overcome,  the  nature  of  which  you  can 
readily  guess.  But  I  add  that  this  sign  must  be  placed  in 
the  front  rank  ;  it  is  only  capable  of  application  in  the  hands 
of  a  medical  man,  and  it  ought  to  be  resorted  to  in  doubtful 
cases.  Only  it  will  be  necessary  to  take  the  temperature 
twice,  at  an  interval  of  some  hours. 

Necrometers  or  thanatometers  have  been  constructed  on 
this    principle.       They    are    graduated    instruments    which 


PARCHMENT  PATCHES.— BURNS.  6$ 

indicate  certain  death,  probable  death,  etc.,  according  as  the 
column  of  mercury  rises  or  falls  to  points  fixed  beforehand. 

These  instruments  cannot  be  managed  by  non-medical 
persons  ;  it  is  the  same  in  using  them  as  in  taking  the 
temperature  of  patients ;  you  all  know  how  difficult  it  is  in 
practice  to  take  a  patient's  temperature,  and  how  untrust- 
worthy are  the  figures  when  it  has  been  taken  by  the  patient 
himself  or  by  one  of  his  friends. 

PARCHMENT  PATCHES.— BURNS. 

I  wish  also  to  say  a  few  words  on  the  search  for  parchment 
patches.  When  the  epidermis  is  removed  from  a  greater  or 
less  extent  of  the  skin  of  a  dead  body,  the  exposed  cutis 
becomes  like  parchment  in  about  eight  hours,  and  yields  a 
sharp  sound  when  tapped  with  a  scalpel.  This  is  not  an 
easy  sign  to  obtain  except  in  a  hospital,  and  consequently 
is  not  of  much  practical  value. 

I  shall  say  as  much  with  regard  to  burns.  Stress  has 
often  been  laid  on  the  difference  between  burns  made  during 
life  and  those  made  after  death.  During  life  a  burn  pro- 
duces a  blister  surrounded  by  a  reddish  areola,  and  con- 
taining an  albuminous  liquid.  When  the  blister  breaks, 
there  is  seen  beneath  it  a  network  of  small  dilated  vessels. 
Are  these  phenomena  constant  during  life  ?  Is  there  always 
albumen  in  the  serum  ?  No.  When  an  individual  dies  at 
the  moment  he  is  burnt,  blisters  are  produced,  but  no  con- 
gestion. When  the  explosion  occurred  in  the  Rue  Beranger, 
in  Paris,  Mme.  Mathieu  perished  in  an  atmosphere  the  tem- 
perature of  which  exceeded  for  a  moment  3,600°  F.  The  body 
was  blistered  all  over,  but  it  was  impossible  to  recognise  any 
reddish  areola  or  congestion  of  the  skin,  or  any  albumen  in 
the  blisters.*  That  means,  in  plain  terms,  that  the  individual 
must  have  lived  longer  for  these  phenomena  to  be  produced. 

In  the  dead  body  a  burn  may  cause  a  blister,  but  it  will 
not  form  an  areola.  Let  a  drop  of  melted  sealing-wax  fall 
on  to  a  limb  that  has  just  been  amputated,  and  you  will 
succeed  in  producing  a  blister. 

*  Brouardel,  '  Etude  m^dico-legale  sur  la  Combustion  du  Corps 
humain'  {Ann.  d^Hyg.,  1878,  2*  serie,  tome  l,  p.  509). 

5 


66  THE  SIGNS  OF  DEATH. 

The  test  of  burning  is  therefore  a  doubtful  sign,  and  one 
against  which  I  would  put  you  on  your  guard.  Consent  is 
readil}^  given  to  its  employment  by  the  public,  and  burns 
are  made — often  very  severe  ones — by  applying  heated  flat- 
irons  to  the  heels  of  dead  persons  of  whose  death  it  is 
desired  to  obtain  assurance.  On  the  other  hand,  revulsives 
sometimes  take  no  effect,  even  while  the  individual  is  still 
alive  ;  do  not  the  attendants  on  a  patient  say,  '  Oh,  he  is 
dead  ;  the  mustard-plasters  and  blisters  do  not  take  any 
longer!'  A  sign  quite  as  uncertain  is  that  of  M.  Marteno 
of  Cordova  ;  he  advises  us  to  apply  the  flame  of  a  candle  at 
the  distance  of  half  an  inch  from  the  extremity  of  the 
fingers  or  toes ;  if  death  is  real,  the  epidermis  of  that  part 
of  the  finger  exposed  to  the  flame  dries  up  and  separates 
from  the  cutis  ;  it  forms  an  air-blister,  which  bursts  suddenly 
with  a  disengagement  of  gas  which  is  sometimes  strong 
enough  to  blow  the  candle  out.  This  is  an  elegant  experi- 
ment to  perform  in  a  course  of  lectures,  but  it  is  scarcely 
conclusive.  The  explosive  blister  may  also  be  produced 
during  the  last  moments  of  life. 

I  prefer  to  use  '  Mayor's  hammer.'  It  is  an  ordinary 
hammer,  which  has  to  be  wetted  with  boiling  water,  and  is 
then  applied,  after  being  dried,  to  the  hollow  of  the  epigas- 
trium. It  is  an  excellent  means  of  reviving  a  person  who 
has  fallen  in  a  state  of  syncope.  The  worst  that  can  happen 
is  that  it  forms  a  bulla  on  the  place  where  the  hammer 
touched.  This  plan  may  be  always  tried  ;  but  I  should  not 
Hke  to  popularize  Marteno's  explosive  blister. 

What  conclusions  may  be  drawn  from  this  exposition  ? 

There  exist  many  excellent  signs  which  enable  a  medical 
man  to  say  :  '  This  man  is  actually  dead.'  However  little 
doubt  a  physician  may  have,  still  he  ought  to  make  use  of 
the  various  tests  that  have  been  passed  under  review,  and, 
if  need  be,  to  wait  and  not  pronounce  an  opinion  until 
absolute  certainty  can  be  obtained. 

But  when  there  is  no  medical  man  to  verify  death,  it  may 
happen  that  persons  only  apparently  dead  may  be  taken  to  be 
really  dead.  It  is  therefore  necessary,  on  all  grounds,  to 
entrust  the  duty  of  deciding  whether  a  person  is  dead  or 


PARCHMENT  PATCHES.— BURNS.  67 

not  to  a  medical  man  ;  for  he  alone  is  capable  of  estimating 
the  value  of  the  signs,  and  to  make  an  exact  diagnosis,  as 
he  would  in  the  case  of  a  disease. 

The  conclusion  to  be  drawn  from  all  these  facts  that  we 
have  established,  Gentlemen,  is  that  the  combination  of 
signs  of  death  gives  us  almost  complete  certainty  of  death, 
if  we  are  physicians,  if  we  have  thought  the  question  out, 
and  if  we  make  a  diagnosis  such  as  we  are  not  accustomed 
to  make  unless  we  have  learnt  to  do  so  in  the  hospitals. 
But  I  believe  that  it  is  right  to  remain  in  a  state  of  philo- 
sophic doubt ;  we  know  that  apparent  death  may  last  for  a 
longer  or  shorter  time,  and  that  in  three  cases  at  least  (viz., 
the  men  who  were  hanged  at  Boston  and  Buda-Pesth,  and 
the  woman  who  was  buried,  as  described  by  Dr.  Roger), 
persons  considered  to  be  dead  have  been  recalled  to  life. 
In  the  German  mortuary  chambers,  some  of  which  have 
been  in  existence  for  more  than  a  century,  where  every  pre- 
caution is  taken,  where  every  corpse  has  a  bell-rope  placed 
in  its  hand,  only  once  has  the  bell  been  rung  .  .  .  the  hand 
of  the  corpse  shook  the  cord  of  the  bell  at  the  moment  when 
rigor  mortis  passed  off,  so  that  the  arm  fell  down. 

The  verification  of  death  should  therefore  always  be 
entrusted  to  a  physician,  who  alone  is  competent  to  estimate 
the  value  of  the  different  signs  that  we  have  just  been 
examining  together;  I  believe  that  accidents  will  then  be,  if 
not  impossible,  at  any  rate  infinitely  rare,  and  1  am  obliged 
to  add  that  though  there  is  a  great  improbability  of  a  living 
person  being  buried  alive  under  those  conditions  in  which 
verification  of  death  is,  or  rather  is  not,  performed,  still,  it  is 
impossible  to  assert  that  that  direful  contingency  might  not 
happen. 

We  thus  at  last  arrive  at  the  same  conclusions  that  were 
formulated  by  the  Academy  of  Medicine  with  regard  to  the 
competition  instituted  by  the  Marquis  d'Ourches  in  1874.'^ 
In  short,  said  the  Academy,  the  signs  of  death  are  certain 
enough  to  render  all  mistakes  impossible,  provided  that 
verification  of  death  by  a  medical  man  is  made  universal 
throughout   the  communes  of  France,  and   if  the  medical 

*  Devergie,  Ann.  d^Hyg.,  2*^  serie,  tome  xxvii.,  p.  293. 


68  THE  SIGNS  OF  DEATH. 

man  has  skill  enough  to  make  the  diagnosis.  But  we  are 
compelled  to  acknowledge  (i)  that  in  25,000  out  of  36,000 
communes  (two-thirds  of  the  population)  this  verification 
is  not  performed  at  all  ;  (2)  that  this  portion  of  science 
is  too  much  neglected,  and  that  the  attention  of  medical 
men  is  not  called  with  sufficient  insistence  towards  this 
branch  of  diagnosis.  Dr.  Armaingaud*  adopts  the  same 
conclusions. 

*  '  CEuvre  de  I'Enseignement  elementaire,'  April,  1893. 


LECTURE    IV. 

RIGOR  MORTIS. 

Gentlemen, — We  have  to  study  two  other  signs  of  death, 
rigidity  and  putrefaction,  which  appear  at  a  later  period. 
These  two  signs  are  almost  incontrovertible. 

When  we  meet  with  putrefaction,  there  can  no  longer  be 
any  doubt  at  all  as  to  the  reality  of  death. 

With  regard  to  rigor  mortis  we  shall  have  to  make  some 
reserve,  just  as  we  did  for  the  cessation  of  circulation  and 
the  fall  of  temperature.  When  a  person  is  dead,  not  much 
time  should  be  wasted  before  covering  the  body  with  the 
burial  garments.  Rigor  mortis,  as  all  nurses  know,  would 
soon  make  it  impossible  to  put  them  on. 

Is  rigor  mortis  a  constant  sign  of  death  ?  Louis,  who 
would  have  thought  it  a  dishonour  to  medicine  to  be  unable 
to  determine  the  reality  of  death,  states  in  one  of  his 
memoirs  that  he  found  rigor  mortis  in  every  one  of  five 
hundred  bodies  that  he  had  examined.  And  yet  a  great 
many  authors  have  disputed  its  constancy. 

Haller,  who  watched  by  the  body  of  his  daughter  for 
forty-eight  hours,  declared  that  he  could  not  discover  rigor 
mortis  in  her  at  any  moment.  Those  who  maintain  the 
constancy  of  the  phenomenon  have  replied  as  an  objection 
that  Haller  was  not  really  in  a  proper  mood  for  observing. 
Other  authors  have  shown  that  in  still-born  children  and  in 
the  foetus  rigor  mortis  is  often  wanting.  The  partisans  of 
its  constancy  have  not  failed  to  give  as  an  explanation  of 
this  that  rigidity  had  existed  while  in  the  uterus,  and  that 
the  foetus  had  only  been  expelled  when  rigidity  had  passed 
away. 


70  THE  SIGNS  OF  DEATH. 

Bichat,  who  was  a  first-class  observer,  stated  that  rigidity- 
did  not  occur  in  persons  suffocated  by  charcoal.  He  must 
have  met  with  cases  in  which  it  was  really  absent,  or  in 
which  it  was  so  slightly  marked  as  to  escape  detection.  In 
all  the  cases  of  asphyxia  by  carbonic  oxide,  or  by  the  fumes 
of  charcoal,  as  it  is  commonly  called,  on  which  I  have  been 
called  to  pronounce  an  opinion,  I  have  always  found  very 
marked  rigor  mortis. 

Bichat  had  expressed  the  same  opinion  about  individuals 
struck  dead  by  lightning.  M.  Tourdes,  who  has  happened 
to  meet  with  three  cases  of  death  by  lightning,  has  testified 
to  the  presence  of  rigidity  in  all  of  them.  We  may  say,  then, 
that  rigor  mortis  is  a  nearly  constant  phenomenon  in  adults, 
but  it  maybe  so  slightly  marked  in  certain  cases  as  to  escape 
the  notice  of  the  most  painstaking  observer. 

When  rigidity  is  complete,  the  corpse  may  be  moved  like 
a  plank;  the  body  takes  a  characteristic  position  :  the  lower 
limbs  are  extended,  the  upper  limbs  semi-flexed,  the  hands 
clenched  ;  this  is  the  attitude  which  Devergie  has  called 
'  the  attitude  of  combat.' 

Rigor  mortis  is  often  of  extreme  intensity  ;  it  is  sometimes 
impossible  to  flex  the  thigh  on  the  pelvis,  or  to  separate  the 
jaws. 

Two  interesting  points  must  be  noted.  The  rigidity  and 
muscular  contraction  may  be  so  great  that,  even  without 
making  extension,  the  muscular  fibres  are  ruptured  here  and 
there  ;  it  is  a  tearing  of  isolated  bundles  of  fibres.  When, 
on  the  contrary,  the  limb  of  a  frozen  body  is  forcibly 
stretched  out,  ruptures  of  the  muscular  tissue  are  produced 
likewise,  but  these  are  ruptures  of  larger  masses  of  muscle, 
of  irregular  shape.  M.  Tourdes,  in  order  to  measure  the 
intensity  of  rigidity,  introduced  discs  of  stearine  between 
the  jaws  of  persons  just  dead.  When  rigor  mortis  became 
established,  the  teeth  dented  the  two  surfaces  of  these  discs, 
and  often  left  marks  one-eighth  to  one-fifth  of  an  inch  deep. 
This  experiment  shows  that  there  is  a  violent  contraction 
during  the  production  of  rigidity. 

Murderers  sometimes  try  to  take  advantage  of  cadaveric 
rigidity.     They  place  a  knife  or  a  revolver  in  the  hand  of  the 


RIGOR  MORTIS.  yi 


victim,  which  is  about  to  close.  The  magistrate  who  has  to 
take  the  first  evidence  has  great  difficulty  in  withdrawing  the 
weapon  from  the  hand  stiffened  in  death;  the  presumption 
of  suicide  appears  natural.  This  is  a  species  of  simulation 
of  which  it  may  be  useful  to  forewarn  you. 

When  it  is  important  to  know  whether  the  stiffness  of  a 
body  is  due  to  rigor  mortis,  or  to  any  other  cause,  the  best 
plan  is  to  attempt  to  extend  the  limbs.  If  rigidity  has  but 
recently  set  in,  the  extended  arm  contracts  again  and  returns 
to  its  former  position.  If  rigidity  is  passing  awa}',  the  arm 
remains  straight  and  contracts  no  more.  This  secondary 
contraction  does  not  occur  in  frozen  muscles. 

At  what  moment  does  rigor  mortis  appear  ?  That  is  an 
important  question  for  the  medical  jurist.  How  many  times 
have  I  not  read  with  regret  this  phrase  in  medico-legal 
reports  :  '  Death  must  have  happened  within  the  last 
five  or  six  hours,  because  rigor  mortis  has  not  yet 
appeared.' 

Or  this  other  phrase  :      '  X must  have  been  dead  at 

least  twelve  or  fourteen  hours,  since  rigor  mortis  is 
present.' 

Gentlemen,  when  we  have  to  do  with  a  corpse,  uninvaded 
as  yet  by  rigor  mortis,  all  we  can  say  is  that  death  happened 
not  long  ago  ;  it  is  impossible  to  fix  the  time  that  has  elapsed 
with  exactitude. 

Nysten  asserted  that  rigidity  appeared  as  soon  as  the 
bodily  heat  had  disappeared.  This  is  not  correct;  it  appears 
much  sooner.  Niederkorn  found  that  in  103  corpses  observed 
by  him  it  appeared  : 

2  hours  after  death  in    2  cases. 


om 

2   to 

4 

55                 5 

45 

)) 

4  „ 

6 

55                 ) 

24 

)5 

6  „ 

8 

55                 5 

18 

)» 

«  „ 

10 

5)                 5 

II 

!J 

10  „ 

13 

55                 5 

3 

Total  103      „ 

In  a  general  way,  therefore,  it   is   from   the   third   to   the 
sixth  hour  that  rigor  mortis  first  appears. 

Other  authors  have   made   interesting  remarks.     Brown- 


72  THE  SIGNS  OF  DEATH. 

Sequard,  for  example,  in  1848,  met  with  rigidity  affecting 
the  jaw  in  a  patient  suffering  from  typhoid  fever  a  quarter 
of  an  hour  before  he  died.  Immediately  afterwards  it  spread 
over  the  whole  body  ;  but  it  disappeared  at  the  end  of  thirty 
minutes,  and  did  not  return. 

Gentlemen,  when  one  is  performing  the  experiments  of 
injecting  guinea-pigs  and  rabbits  with  septic  substances, 
capable  of  setting  up  fermentation,  rigoi'  mortis  may  be  found 
setting  in  a  quarter  of  an  hour  or  longer  before  death.  This 
fact  should  be  borne  in  mind. 

Remember,  also,  what  I  told  you  about  persons  dying 
suddenly  from  injury  of  the  cervical  spinal  cord  ;  they  pre- 
serve in  their  rigidity  the  attitude  they  were  in  at  the  moment 
they  were  struck.  I  did  not  give  you  any  explanation  of  this 
fact,  and  will  not  attempt  to  do  so  to-day,  either.  Lastly,  as 
m}^  own  experience  has  shown,  after  poisoning  by  a  large 
dose  of  strychnine,  rigor  mortis  follows  immediately  upon 
the  phenomena  of  contracture  which  existed  at  the  time  the 
patient  died. 

With  regard  to  the  duration  of  rigidity,  we  are  also 
obliged  to  make  allowance  for  different  influences.  It  lasts 
on  an  average  twenty-four  to  forty-eight  hours.  It  may, 
however,  last  for  a  few  hours  only ;  at  other  times  it  persists 
for  five,  six,  or  seven  days.  Our  data  with  reference  to  this 
subject  are  very  scanty.  We  know  that  in  exhausted  indi- 
viduals, such  as  those  dying  of  cancer  or  phthisis,  rigor 
mortis  appears  early,  but  does  not  last  long  ;  on  the  con- 
trary, in  an  individual  dying  while  in  good  health,  it  appears 
late  and  is  of  long  duration.  These  facts  are  of  importance 
in  forensic  medicine.  Cadaveric  rigidity  appears  first  in  the 
muscles  of  the  lower  jaw,  then  in  those  of  the  neck  and  eye- 
lids, then  the  lower  limbs,  and  lastly  the  upper  limbs.  Too 
great  importance  must  not  be  attached  to  this  particular 
order.  The  only  thing  needful  to  remember  is  this :  that 
the  duration  of  rigor  mortis  is  nearly  the  same  in  each  of  the 
members  invaded  ;  also  that  the  part  which  was  invaded 
last  will  keep  it  last.  Experience  has  taught  us  that  the 
muscles  of  the  fingers,  as  a  matter  of  fact,  preserve  their 
rigidity   latest.      It    is   possible   to   infer   from    these   facts 


RIGOR  MORTIS.  73 


an  indication,  but  no  positive  evidence,  of  the  moment  of 
death. 

The  muscles  of  vegetative  Hfe  are  affected  hke  the  rest. 
Rigidity  of  the  muscles  of  the  skin,  which  is,  however,  of 
short  duration,  gives  to  this  structure  the  appearance  of 
cutis  anserina.  Rigidity  of  the  dartos  is  very  plain.  I  do  not 
know  what  made  Casper  assert  that  retraction  of  the  dartos 
took  place  only  in  those  who  have  been  drowned  ;  nothing 
is  further  from  the  truth. 

The  muscles  of  the  intestinal  walls  may  present  a  certain 
degree  of  rigidity.  That  of  the  vesiculce  seminales  is  constant 
and  early.  Half  an  hour  after  the  execution  of  the  anarchist 
Henry,  the  two  vesicles  were  as  hard  as  small  chestnuts. 
Their  contraction  induces  the  expulsion  of  the  spermatic 
fluid  which  they  contain.  When  the  individual  has  died 
in  good  health,  the  spermatozoa  contained  in  the  expelled 
semen  may  retain  their  movements  for  twenty-four  hours. 

The  muscle  of  the  heart  does  not  escape  rigidity.  Gentle- 
men, all  the  treatises  on  medical  jurisprudence  contain 
regrettable  errors  on  this  subject.  The  results  of  experi- 
ments conducted  in  the  laboratory  have  been  falsely  apphed 
to  the  results  of  medico-legal  autopsies.  It  has  been 
attempted  to  compare  the  facts  of  experience  with  the 
results  of  ingenious  experiments. 

In  a  laboratory,  an  animal  is  killed  by  means  of  some 
toxic  substance  or  other,  the  body  is  immediately  opened, 
and  it  is  found  that  the  heart  is  either  in  systole  or  diastole. 
In  a  singularly  inconsequent  way,  medical  jurists  have 
attempted  to  make  this  same  procedure  apply  to  the  human 
corpse,  and  have  claimed  that  they  can  determine,  accord- 
ing as  the  heart  is  in  systole  or  diastole,  whether  there  has 
been  poisoning  by  any  given  substance.  But  an  autopsy  is 
never  performed  immediately  after  death,  especially  in 
medico-legal  cases.  When  there  is  a  question  of  poisoning, 
the  time  which  elapses  between  the  decease  and  the  post- 
mortem examination  far  exceeds  twenty-four  or  forty-eight 
hours.  A  suspicious  death  gives  rise,  as  a  matter  of  fact,  to 
rumours  that  are  more  or  less  definite.  The  attention  of 
the  public  prosecutor  is  drawn  to  the  matter,  but  he  cannot 


74  THE  SIGNS  OF  DEATH. 


intervene  at  once.  He  has  to  obtain  evidence  before  putting 
the  law  in  motion.  The  autopsy  does  not  take  place,  in 
nine  cases  out  of  ten,  for  three  weeks,  or  sometimes  a  year 
or  more,  after  death  occurred.  When  the  medical  jurist 
endeavours,  therefore,  to  draw  decided  conclusions  from 
laboratory  experiments,  he  makes  a  mistake. 

When  an  individual  dies,  the  heart  is  sometimes  in  a  state 
of  rigidity.  That  of  the  anarchist  Henry  was  in  a  state  of 
absolute  rigidity  half  an  hour  after  his  execution.  It  is  then  in 
systole.  When  the  rigidity  has  passed  away,  it  is  in  diastole. 
In  an  autopsy  which  I  performed,  in  conjunction  with 
M.  Vibert,  eight  hours  after  death,  the  heart  was  in  com- 
plete rigidity.  When  rigidity  seizes  the  cardiac  muscle,  this 
contracts,  and  expels  the  blood  which  is  within  its  cavities. 
As  soon  as  the  rigidity  is  gone,  it  is  filled  afresh,  because  it 
has  become  distensible. 

Refer  to  the  trial  of  La  Pommerais.*  Physiologists  and 
physicians  were  called  to  give  evidence  at  the  Assize  Court. 
The  president  put  this  question  to  them  :  '  When  a  person 
dies  from  poisoning  by  digitalis,  what  appearances  does  the 
heart  present  ?'  Claude  Bernard,  Vulpian,  H.  Bouley,  and 
others,  did  not  agree.  None  of  them  made  any  allusion  to 
the  normal  rigidity  of  the  heart  muscle.  You  know  the  facts 
of  that  notorious  case.  Mme.  de  Paw  was  ill.  One  evening 
Dr.  Blachez  returned  home  ;  his  hall-porter  and  the  porter 
from  a  neighbouring  house  told  him  that  a  woman  was  dying 
in  the  house  opposite,  and  begged  him  to  go  and  attend  to 
her.  Dr.  Blachez,  after  some  hesitation,  decided  to  go  up- 
stairs to  see  the  patient.  He  saw  her,  came  downstairs 
again,  and  went  to  find  a  police  officer,  to  whom  he  com- 
municated his  opinion  that  this  woman  was  dying  from 
poisoning  by  digitalis.  It  is  possible  that  he  took  into 
account,  in  making  his  diagnosis,  certain  information  that 
was  supplied  to  him  by  those  in  attendance  on  the  patient. 
Thus,  a  formal  deposition  had  been  made  before  a  magis- 
trate,   which    is    very    rare.     It    was    known,    besides,   that 

■*  Tardieu,  '  Relation  mddico-l^gale  de  I'Affaire  Couty  de  la  Pommerais, 
empoisonnement  par  la  Digitaline'  (Ann.  iVHyg..,  1864,  tome  xxii., 
p.  80). 


RIGOR  MORTIS.  75 


Mme.  de  Paw  was  the  mistress  of  a  medical  man,  La  Pom- 
merais,  who  had  effected  an  insurance  on  her  hfe  some 
months  before.  The  law  took  up  the  case  then  with  excep- 
tional rapidity.  A  post-mortem  was  made  twenty  hours 
after  death,  and  the  heart  was  found  contracted  rigidly  in 
systole. 

Many  animals  die  with  the  heart  in  systole,  even  without 
having  been  poisoned  by  digitalis.  It  is  the  same  with 
animals  into  which  suspected  products  obtained  from  corpses 
have  been  injected.  In  the  discussion  which  followed, 
M.  Hebert,  head  dispenser  of  the  Hotel-Dieu,  made  the 
remark  that  frogs  and  rabbits  into  which  a  maceration  of 
scrapings  of  the  floor  had  been  injected,  died  with  the  heart 
in  systole  likewise.  This  experiment  of  M.  Hebert  is  not 
understood  yet.  Gentlemen,  it  contains  the  germ  of  the 
recent  researches  on  ptomaines.  La  Pommerais  was  found 
guilty.  I  am  convinced  that  he  was  so ;  but  the  scientific 
discussions  which  took  place  during  his  trial  prove  once 
again  with  what  reserve  we  ought  to  make  our  affirmations 
before  the  magistrate.  The  heart  behaves  after  death  like 
an  ordinary  muscle  ;  it  undergoes  rigor  mortis.  This  rigidity 
ceases  after  a  certain  time  ;  but  it  is  quite  impossible  for  us 
to  assert  what  its  duration  is. 

It  often  happens  that  the  magistrate  will  ask  you  how 
long  it  is  since  death  occurred.  This  is  a  very  important 
question,  for  it  may  serve  to  assign  responsibility.  Never 
say  in  your  reports,  as  I  have  seen  done,  alas  !  too  often : 
'  Rigor  mortis  is  complete,  therefore  death  took  place  five 
hours  ago.'  You  can  say,  if  rigidity  is  complete,  that  death 
is  recent,  but  it  is  difficult  to  say  any  more  ;  and  in  support 
of  your  assertion  you  can  refer  to  Niederkorn's  table.  The 
conditions  have  been  studied  which  affect  the  development 
of  rigor  mortis.  When  it  is  cold,  it  is  said  rigidity  appears 
late  and  is  prolonged  ;  with  heat  it  is,  on  the  contrary,  early 
and  brief.  Such  is  the  formula  which  you  will  find  in  books 
and  treatises ;  it  is  properly  contradicted  by  Brown-Sequard. 
Claude  Bernard,  who  was  not  satisfied  with  words,  placed 
rabbits  in  chambers  heated  to  yf  F.  Rigidity  appeared 
slowly,  and  was  prolonged  for  more  than  forty-eight  hours. 


76  THE  SIGNS  OF  DEATH. 

Claude  Bernard's  experiments*  are  thus  in  apparent  con- 
tradiction to  everyday  experience.  We  shall  find  the  ex- 
planation when  we  come  to  stud}^  sunstroke  and  heat- 
stroke. 

Practical  experience  shows  us  that  in  the  post-mortem 
theatre,  with  a  warm  and  moist  atmosphere,  rigidity  is 
early  and  short.  I  admit  the  truth  of  this  general  state- 
ment, but  I  do  not  dispute  Claude  Bernard's  experiments. 
When  a  dog  dies  in  consequence  of  sunstroke,  it  is  already 
in  a  state  of  rigidity,  even  while  it  still  breathes.  It  dies 
when  the  heart  stops,  and  this  organ  becomes  rigid  imme- 
diately. M.  Vallin-|-  relates  that  when  he  was  in  Algeria 
he  opened  the  bodies  of  dogs  dying  from  this  cause,  and 
that  their  hearts  yielded  a  sound  when  cut  like  that  of  a 
piece  of  wood.  When  people  die  from  sunstroke  in  India, 
or  even  in  Europe — for  example,  in  the  case  of  troops  who 
go  into  a  wood  to  rest,  where  the  air  is  hot  and  close — 
rigidity  appears  very  late. 

In  the  face  of  these  contradictory  results,  we  must  con- 
clude that  other  factors  are  concerned,  which  we  already 
suspect,  and  which  I  will  indicate  to  you  directly.  Devergie 
had  a  formula  concerning  the  duration  of  rigor  mortis  which 
I  must  repeat  to  you.  He  said  :  Winter  and  summer  alike, 
the  figure  remains  the  same  ;  only  in  winter  it  stands  for 
days,  in  summer  for  hours.'  Remember  this  formula,  but 
do  not  apply  it  too  rigorously. 

Rigor  mortis  may  be  produced  experimentally  in  a  muscle 
by  loading  it  with  a  weight.  Take  a  dog  that  has  just 
been  killed,  and  hang  a  weight  to  one  of  its  paws  :  rigidity 
will  appear  sooner  in  that  paw  than  in  the  others. 

When  animals  are  fatigued,  rigidity  appears  with  rapidity. 
It  is  often  noticed  in  hunting,  and  in  cock-fights  where 
the  animal  is  exhausted,  that  rigidity  follows  immediately 
upon  death.  Some  sportsmen  maintain  that  the  driven 
animal  stops  stiffened  in  death.  Thus,  in  overwork  rigidity 
is  precocious  and  brief,  and  it  may  be  added  that  putre- 
faction follows  quickly. 

*  Claude  Bernard,  '  Legons  sur  la  Chaleur  animale.'     Paris,  1876. 
t  Vallin,  Archives  de  Me'dechte. 


RIGOR  MORTIS.  77 


I  believe  that  rigor  mortis  can  teach  ns  nothing  of  scientific 
value  in  cases  of  poisoning.  The  results  of  different  obser- 
vations do  not  agree,  and  they  vary  of  course  according  to 
the  poison  that  is  used,  its  dose,  and  the  accompanying 
circumstances.  We  have  seen  that  in  poisoning  by  a  large 
dose  of  strychnine  rigidity  may  be  immediate ;  but  when 
the  dose  of  strychnine  absorbed  has  not  produced  death 
speedily,  but  has  caused  a  succession  of  convulsive  attacks, 
with  more  or  less  well-marked  intervals  of  quiescence,  and 
the  individual  dies  during  one  of  these  periods  of  calm, 
rigor  mortis  does  not  take  place.  It  would  seem  that  in 
such  cases  the  muscles  had  spent  all  their  force  in  con- 
vulsions. Well-contrived  experiments  could  alone  give  us 
the  key  to  these  variations. 

Laennec  states  that  rigidity  lasts  a  long  while  in  cases  of 
sudden  death.  You  will  see.  in  the  course  of  these  lectures 
that  the  causes  of  sudden  death  are  too  numerous  to  permit 
us  to  accept  this  formula.  In  paralysed  persons  it  is  more 
marked  in  the  paralysed  than  in  the  healthy  muscles.  In 
childhood  and  old  age,  rigidity  would  appear  earlier  and  last 
longer  (Louis). 

What  is  rigor  mortis,  then  ?  What  is  its  nature  ?  I  will 
not  say  anything  about  the  discussions  to  which  these 
questions  gave  rise  in  bygone  times.  Amongst  our  con- 
temporaries, Kiihne  of  Heidelberg,  a  former  assistant  of 
Claude  Bernard,  believes  that  rigidity  is  due  to  the  coagula- 
tion of  myosin,  an  albuminous  substance  contained  in  the 
muscular  tissue.  Brown-Sequard  has  raised  objections  to 
this  theory  on  the  ground  that  the  coagulation  of  an  albu- 
minoid substance,  however  complete  it  might  be,  could  not 
produce  in  the  contracted  muscle  a  rigidity  equal  to  that  of 
rigor  mortis. 

MM.  Tourdes  and  Feltz  have  examined  microscopically 
muscles  in  the  state  of  rigidity,  but  they  have  found  nothing 
which  distinguishes  them  from  others.  Some  observers 
have  shown  that  muscles  present  an  acid  reaction  during 
rigidity  (lactic  acid  had  already  been  detected  in  the  muscles 
of  over-worked  or  over-driven  animals) ;  the  conclusion  has 
been  drawn   that  the  production  of  rigidity  is  due  to  the 


78  THE  SIGNS  OF  DEATH. 

transformation  of  alkaline  substances  in  the  muscle  into 
acids  ;  but  Achtakaweski  has  proved  that  in  tetanus  the 
muscles  are  not  acid,  and  that  the  injection  of  an  alkali 
into  the  muscular  tissue  does  not  prevent  rigidity. 

Beclard  tied  all  the  vessels  of  a  limb,  and  made  the 
posthumous  circulation,  of  which  I  have  spoken  to  you,  im- 
possible, yet  rigidity  takes  place  all  the  same  ;  moreover,  the 
nerves  have  been  divided,  and  rigidity  appears  nevertheless. 

M.  Achtakaweski  has  shown  that  muscles  in  tetanic  con- 
traction had  no  acid  reaction  ;  M.  Laborde  has  reached  the 
same  conclusion  by  thrusting  steel  needles  into  muscles  in  a 
state  of  rigidity  ;  these  needles  did  not  become  oxidized, 
although  they  did  so  rapidly  under  the  same  conditions 
during  life.  Brown-Sequard  removed  the  spinal  cord  from 
an  animal,  and  found  that  rigidity  was  not  produced  in  such 
a  case.  He  has  drawn  from  this  experiment,  which  I  have 
not  repeated,  conclusions  which  absolutely  contradict  those 
of  Beclard ;  is  not  division  of  all  the  nerves  equivalent 
a  priori  to  removal  of  the  spinal  cord  ? 

Rigor  mortis  is  probably  only  one  of  the  first  phenomena 
of  putrefaction,  not  as  regards  the  sense  of  smell,  but  as 
regards  the  chemical  processes  which  cause  the  muscles  to 
contract.  Herzen*  has  proved  that  there  is  found  in  the 
muscular  tissue  of  a  dead  animal  an  acid  which  he  calls 
'  sarcolactic  acid  ';  it  is  to  the  action  of  this  that  he  attri- 
butes muscular  contraction.  By  injecting  some  drops  of 
this  acid  into  the  muscles  of  dead  animals  he  caused  rigor 
mortis  to  appear  in  cases  which  had  not  as  yet  exhibited  it. 

To  sum  up,  we  may  conclude  that  rigor  mortis  is  an 
almost  constant  sign  of  death,  that  it  manifests  itself  in  from 
three  to  five  hours  after  death,  that  it  lasts  on  an  average 
twenty-four  to  thirty-six  hours,  and  that  .it  sometimes  is 
present  in  an  extreme  degree  of  intensity.  But  the  actual 
data  of  science  do  not  allow  us,  from  a  medico-legal  point  of 
view,  to  deduce  any  positive  conclusion.  The  mode  of  pro- 
duction and  the  causes  of  rigidity  are  still  almost  unknown 
to  us ;  it  is  probable,  however,  that  the  muscular  tissue  is 
invaded  after  death  by  micro-organisms,  to  the  secretions  of 
which  rigidity  is  due. 

*  Herzen,  Setnaine  medicale.i  1886. 


LECTURE  V. 

PUTREFACTION. 

Gentlemen, — The  study  of  putrefaction  is  of  great  im- 
portance in  forensic  medicine.  It  is  caused  by  the  persistence 
of  the  chemical  phenomena  which  take  place  in  the  human 
body  after  death  ;  its  effect  is  to  alter  to  a  singular  degree 
the  appearances  of  the  lesions  resulting  from  disease  or  from 
wounds. 

It  produces  alterations  in  the  colour,  and  transports  the 
blood  into  regions  of  the  body  which  were  not  at  all  con- 
gested during  life.  There  are,  then,  sources  of  fallacy  for 
those  medical  men  who  are  not  accustomed  to  make 
autopsies,  and  which  we  must  take  pains  to  explain. 

Lastly,  we  may  be  able,  thanks  to  what  we  know  to-day 
of  the  phenomena  of  putrefaction,  to  say  to  the  magistrate  : 
'  The  individual,  whose  body  you  have  laid  before  me,  died 
at  such  and  such  a  time.'  The  observations  of  M.  Megnin, 
who  has  carefully  studied  the  insects  which  prey  on  dead 
bodies,  and  which  he  has  picturesquely  styled  '  the  labourers 
of  Death,'  sometimes  allow  us  to  fix  the  dates  with  almost 
mathematical  exactitude. 

GENERAL  THEORY. 

From  a  theoretical  point  of  view,  the  study  of  putrefaction 
is  based  on  the  well-known  experiments  of  M.  Pasteur.  It 
is  he  who  has  actually  proved  to  us  the  non-existence  of 
spontaneous  generation,  which  F.  A.  Pouchet,  of  Rouen, 
maintained  with  much  authority.     M.  Pasteur  experimented 


8o  THE  SIGNS  OF  DEATH. 


on  blood  and  urine,  i.e.,  the  most  fermentible  or  putrescible 
of  organic  liquids.  He  obtained  them  from  the  veins  and 
the  bladder,  quite  out  of  contact  with  the  air,  by  means, 
of  pipettes  that  had  been  passed  through  the  flame 
of  a  lamp  and  then  hermetically  sealed.  These  liquids 
might  be  preserved  for  an  indefinite  time  without  ever 
becoming  tainted  by  putrefaction.  M.  Pasteur's  experiments 
date  from  1854,  yet  the  tubes  containing  blood  and  urine, 
which  he  took  from  the  animals  forty  years  ago,  still  exist  in 
his  laboratory,  and  their  contents  have  undergone  no  change. 
We  are  authorized  to  say,  therefore,  that  organic  material 
derived  from  a  healthy  animal,  so  long  as  it  is  sheltered  from 
the  air,  does  not  putrefy. 

Gentlemen,  when  an  individual  dies,  putrefaction  may 
affect  his  body  in  different  ways,  according  as  it  takes  place 
in  the  open  air,  underground,  in  the  water,  or  in  a  privy. 

In  order  to  give  an  account  to  you  of  the  phenomena 
which  follow  when  putrefaction  occurs  in  the  open  air,  let 
us  first  see  what  takes  place  in  a  blood-clot  which  has  been 
obtained  by  venesection.  The  clot  contracts,  and  soon 
becomes  greenish  on  the  surface.  Take  a  drop  of  this  clot 
and  examine  it.  You  will  find  in  it  micro-organisms  which 
will  have  the  effect  of  liquefying  the  clot  progressively  from 
the  outside  to  the  interior  ;  you  will  find  evidence  of  the 
existence  of  colonies  of  micro-organisms,  only  able  to  live 
in  the  presence  of  oxygen,  which  are  called  aerobic.  These 
aerobic  organisms  produce  carbonic  acid,  and  then  they  dis- 
appear. They  are  replaced  by  a  second  colony  of  micro- 
organisms, able  to  live  either  with  or  without  oxygen,  i.e , 
aerobic  or  anaerobic,  and  to  which  M.  Bordas,  who  has 
written  a  masterly  thesis*  on  the  subject,  calls  'amphibious' 
ifacultatifs) ;  these  also  produce  carbonic  acid,  but  hydrogen 
and  hydrocarbons  as  well.  Lastly,  there  comes  another 
category  of  micro-organisms,  the  anaerobic  class,  which  do 
not  live  in  oxygen,  and  which  produce  hydrogen,  nitrogen, 
and  more  or  less  compound  ammonias.  Remember  this 
triple  evolution  ;  we  shall  often  refer  to  it  subsequently. 

How    do   these  organisms  disappear  ?      They  nearly  all 
*  Bordas,  'Putrefaction,'  1892. 


PUTREFACTION. 


secrete  a  substance  in  the  presence  of  which  they  are  unable 
to  live.  Then  they  disappear,  and  are  replaced  by  other 
colonies,  which  again  are  aerobic.  The  destruction  of  the 
organic  substance  itself  is  hastened,  moreover,  by  fungi, 
and  the  different  species  of  insects  which  have  invaded  it. 

If  it  were  desired  to  comprise  the  phenomena  of  putrefac- 
tion in  a  general  formula,  it  might  be  said  that  these 
processes  constitute  the  return  of  organic  matter  to  inorganic 
matter,  to  the  mineral  kingdom.  The  aerobic,  amphibious, 
and  anaerobic  micro-organisms  produce  carbonic  acid, 
hydrogen,  nitrogen,  and  amines.  The  quaternary  or  nitro- 
genized  matters  have  a  manifest  tendency  to  be  transformed 
into  ternary  or  fatty  substances,  and  these  tend  to  return  to 
binary  compounds.  Place  a  corpse  in  the  water,  and  by 
the  end  of  a  certain  time  you  will  find  that  it  has  undergone 
a  fatty  degeneration.  If  its  sojourn  in  the  water  is  prolonged, 
the  body  will  assume  the  appearance  of  a  mummy,  because 
it  will  have  borrowed  from  the  water  part  of  its  mineral 
constituents. 

Daily  experience  in  the  laboratory  has  for  a  long  while 
familiarized  us  with  certain  facts  which  may  appear  singular: 
everyone  who  has  occupied  himself  with  bacteriology  knows 
that  according  to  the  media  the  colonies  do  or  do  not 
multiply;  it  is  enough  to  alter  the  conditions  of  the  soil, 
sometimes  in  the  most  insignificant  way,  in  order  to  put  a 
stop  to  the  proliferation  of  the  bacilli. 

When  these  facts  are  known,  it  can  be  readily  imagined 
that  there  may  be  considerable  variations  in  the  phenomena 
of  putrefaction,  according  to  the  temperature,  and  according 
to  the  nature  of  the  medium  in  which  the  organism  is  under- 
going putrefaction.  Let  us  take  an  everyday  example : 
If  we  watch  what  goes  on  in  a  piece  of  meat  exposed  to  the 
open  air,  we  shall  see  aerobic  and  amphibious  micro- 
organisms appear  on  the  cut  surface,  and  these  will  penetrate 
by  degrees  into  the  interior  of  the  meat ;  then  the  aerobic 
organisms  disappear ;  the  amphibious  and  the  anaerobic 
organisms  secrete  diastase,  which  soaks  into  the  meat  and 
liquefies  it,  and  putrefaction  becomes  established.  If,  on 
the  contrary,  we  place  the  meat  in  vacuo  under  a  bell-glass 

6 


THE  SIGNS  OF  DEATH. 


in  which  there  is  a  capsule  containing  sulphuric  acid,  it  will 
be  preserved  for  a  very  long  time,  for  it  is  withdrawn  from 
the  contact  and  influence  of  the  external  air. 


PUTREFACTION  IN  THE  OPEN  AIR. 

When  the  body  of  an  adult  putrefies  in  the  open  air,  it  is 
very  evident  that  the  micro-organisms  contained  in  the 
atmosphere,  which  settle  on  the  epidermis,  can  penetrate 
through  this  and  commence  the  work  of  putrefaction. 
Nevertheless,  the  epidermis  resists  their  entrance  for  a  long 
time,  alwa57S  much  longer  than  the  epithelium  placed  at  the 
natural  orifices. 

It  is  through  the  alimentary  canal  that  putrefaction  chiefly 
takes  place. 

M.  Duclaux,  who  has  paid  much  attention  to  the  vibrios 
of  the  intestines,  has  succeeded  in  determining  the  part  they 
play  in  putrefaction.  At  death  they  swarm  ;  they  penetrate 
into  the  intestinal  glands,  come  into  contact  with  dead 
epithelium,  which  they  destroy,  find  their  way  into  the 
veins  and  peritoneum,  and  produce  gases  there,  and  secrete 
diastase  which  liquefies  the  tissues.  What  is  the  conse- 
quence of  this  formation  of  gas  and  diastase?  The  quantity 
of  gas  produced  is  considerable  ;  its  tension  is  sometimes 
equal  to  that  of  ij  atmospheres;  it  also  pushes  up  the 
diaphragm  to  the  third  intercostal  space,  and  drives  the 
liquid  contained  in  the  deep  vessels  towards  the  periphery  ; 
that  is  what  I  have  called  the  posthumous  circulation,  which 
I  have  already  mentioned  to  you. 

Putrefaction  is,  therefore,  especially  a  function  of  the 
processes  which  take  place  in  the  intestines. 

Have  these  facts  any  bearing  on  forensic  medicine  ? 
Certainly.  I  have  quoted  once  before  the  case  of  Barre  and 
Lebiez.  These  two  individuals,  as  you  know,  had  murdered 
a  milk-woman  in  the  Rue  d'Hauteville.  Lebiez  cut  off  both 
the  thighs  of  the  victim,  and  concealed  them  in  a  cupboard 
in  his  room  in  the  Rue  de  Poliveau,  near  the  Salpetriere ; 
the  trunk  of  the  body  was  found  at  Le  Mans.  MM.  G. 
Bergeron,  Delens,  Tillaux,  and  Farabceuf  were  consulted  by 


PUTREFACTION  IN  THE  OPEN  AIR.  83 

the  magistrate,  and  all  thought  that  the  thighs,  when  they 
saw  them,  had  been  but  recently  removed  ;  they  had  not 
even  begun  to  putrefy. 

Gentlemen,  it  was  more  than  a  week  after  the  murder  had 
been  committed.  Barre  and  Lebiez  had  separated  the 
thighs  before  the  micro-organisms  of  the  intestines  had  had 
time  to  act  ;  we  are  therefore  authorized  to  say  that  the 
rapidity  of  putrefaction  is  in  direct  proportion  to  that  with 
which  the  gases  of  the  intestines  circulate  in  the  organism. 

When  we  have  to  do  with  a  new-born  child,  who  has 
swallowed  nothing,  do  we  find  the  course  of  events  to  be  the 
same?  According  to  the  experiments  of  MM.  Ogier  and 
Bordas,  the  course  of  putrefaction  does  not  follow  the  same 
rules  in  still-born  infants  as  in  adults  ;  the  still-born  infant 
has  not  breathed.  On  the  contrary,  in  a  child  who  has 
breathed,  and  who  dies  twenty-four  hours  after  coming  into 
the  world,  the  phenomena  of  putrefaction  are  closely  similar 
to  those  which  are  seen  in  the  adult. 

There  are  also  some  accessory  phenomena.  Our  tissues 
contain  oxygen,  and  the  quantity  of  oxygen  favours  the 
development  of  the  first  (aerobic)  colony. 

But  when  a  person  dies  suffocated  by  carbonic  oxide,  his 
tissues  no  longer  contain  much  oxygen,  and  this  first  colony 
will  have  great  difficulty  in  gaining  a  foothold.  And  thus 
we  sometimes  find  in  these  particular  cases  astonishing 
phenomena  of  preservation. 

Here  is  an  example  :  An  individual  hired  a  room  with  an 
adjoining  dark  closet,  and  suffocated  himself  in  that  closet. 
The  owner  of  the  house  was  not  very  much  astonished  at 
the  disappearance  of  his  lodger;  but,  seeing  that  he  did  not 
return,  he  decided  to  let  the  room  anew,  after  giving  it  a 
thorough  cleaning.  The  new  lodger  went  into  the  little 
closet  on  the  night  of  his  arrival,  and  found  there  the  body 
of  his  predecessor. 

Death  had  taken  place  two  months  previously,  and  yet 
the  body  did  not  present  any  trace  of  putrefaction.  It  is 
true  that  it  was  winter,  and  that  the  temperature  of  the 
closet  had  always  been  low. 

The  phenomena  of  putrefaction  vary  also,   according  to 


THE  SIGNS  OF  DEATH. 


whether  or  not  there  was  food  in  the  stomach  at  the  time  of 
death  ;  and  in  cemeteries  they  are  different,  according  as 
the  body  has  been  placed  in  a  badly-closed  coffin  placed  in 
loose  soil,  or  in  a  tightly-closed  coffin  deposited  in  a  moist 
soil ;  they  differ  also  according  as  the  corpse  is  placed  in  a 
lead  coffin  or  in  one  of  wood. 

Gentlemen,  at  the  Morgue  the  bodies  are  sometimes 
swollen  with  gas,  especially  in  the  months  of  May  and  June. 
The  bodies  of  the  drowned  present  these  phenomena  par- 
ticularly ;  the  swelling  and  distension  may  be  extreme. 

When  these  gases  are  diffused  abroad  they  create  an 
abominable  smell.  To  avoid  this  infection  of  the  atmo- 
sphere, I  prick  the  bodies  to  let  the  gases  escape  ;  then  I  set 
light  to  them  at  the  pricks,  and  long  bluish  flames  start 
forth,  like  those  of  a  blowpipe.  After  a  time  they  are 
extinguished,  either  because  the  tiny  orifices  become  blocked, 
or  because  there  is  no  more  inflammable  gas. 

When  putrefaction  is  more  advanced,  and  there  is  no 
further  distension,  the  gas  does  not  take  fire  ;  in  summer 
they  may  be  lighted  at  the  end  of  the  first  day,  and  burn 
for  two,  three,  or  four  days.  Then  the  combustibility  of  the 
gases  ceases. 

What  has  happened,  then  ?  It  is  very  simple.  Gentle- 
men. At  the  beginning  of  putrefaction  we  have  the 
aerobic  colonies,  which  produce  carbonic  acid  chiefly  ;  their 
period  corresponds  to  the  phase  of  uninflammability  of  the 
gas ;  then  come  the  anaerobic  and  amphibious  colonies  of 
M.  Bordas,  which  produce  hydrogen,  carbonic  acid,  and 
hydrocarbons,  which  are  mostly  inflammable  ;  finally,  the 
reduction  becomes  more  and  more  complete,  and  gives  rise 
to  nitrogen,  hydrogen,  and  compound  ammonias,  the  greater 
part  being  incombustible. 

Thus  we  meet  in  the  post-mortem  theatre  with  the  three 
clearly  defined  phases  which  we  have  already  distinguished 
in  bacteriology. 

I  ought  to  call  your  attention,  while  dealing  with  these 
inflammable  gases,  to  the  possibility  of  the  formation  of 
phosphoretted  hydrogen.  Before  the  time  when  refrige- 
rating apparatus   were  employed    at    the    Morgue,   that    is 


PUTREFACTION  IN  THE  OPEN  AIR.  85 


to  say,  prior  to  1882,  phosphorescence  was  often  noticed 
there,  especially  in  warm  weather,  Will-o'-the-wisps  which 
ran  over  and  around  the  bodies.  It  was  a  very  impressive 
spectacle. 

The  development  of  the  gases,  and  the  tension  which  they 
cause  in  the  interior  of  the  body,  place  the  medico-legal 
expert  in  a  very  difficult  position  when  he  wishes  to  discover 
the  existence  of  lesions  which  have  preceded  death,  or  those 
which  have  immediately  followed  it.  The  colouring  matter 
of  the  blood  abounds  in  the  corpuscles,  stains  the  serum, 
and  passes  through  the  vessels  and  diffuses  itself  in  the 
adjacent  tissues  :  hence  arise  those  spots  on  the  mucous 
membrane  of  the  stomach  which  have  been  taken  as 
evidence  of  poisoning,  and  that  infiltration  of  the  posterior 
parts  of  the  body  which  has  been  taken  for  ecchymosis. 

I  have  already  said  something  of  the  liquefaction  of  the 
blood  ;  I  have  spoken  to  you  of  what  was  called  in  the 
Middle  Ages  '  the  judgment  of  God;'  The  following  example 
will  suffice  to  put  you  on  your  guard  against  a  fallacy  of  the 
importance  of  which  I  need  not  remind  you. 

A  corpse  was  found  in  the  river  Gave  at  Lourdes  ;  it  was 
carried  into  a  shed  ;  the  hour  was  11  o'clock  a.m.,  and  the 
weather  was  very  warm.  The  medical  man  who  examined 
the  body  noticed  some  wounds  on  the  head,  which  he 
thought  were  caused  by  stones  rolled  down  by  the  torrent. 
The  public  prosecutor  was  notified  of  the  case,  and  the  law 
was  put  in  motion ;  some  hours  had  passed  since  the  first 
observations  were  made. 

From  each  of  the  wounds  of  the  head  there  now  flowed 
a  little  liquid  blood,  and  the  physician  who  accompanied  the 
officers  of  the  court  concluded  that  these  wounds  were  recent. 
Investigation  showed,  on  the  contrary,  that  the  man  had 
thrown  himself  into  the  Gave  (it  turned  out  to  be  a  case  of 
suicide)  the  morning  before,  and  that  he  had  been  taken 
out  of  the  water  twenty-four  hours  after  death. 

The  flow  of  blood  was  due  to  the  posthumous  circulation 
induced  by  the  formation  and  accumulation  of  gas  in  the 
abdominal  cavity.  This  development  took  place  only  after 
the  removal  of  the  body  from  the  cold  waters  of  the  Gave. 


86  THE  SIGNS  OF  DEATH. 

When  there  is  no  wound  by  which  the  blood  can  escape, 
a  tolerably  well-marked  congestion  is  produced  in  all  the 
peripheral  parts.  Devergie,  formerly  a  pupil  of  Bichat, 
who  remained  faithful  to  his  master's  theories  to  the  very 
last,  has  accumulated  a  large  number  of  medico-legal  cases. 
In  the  introduction  accompanying  those  dealing  with  sub- 
mersion, he  says  that  when  a  man  is  drowned  he  dies  either 
by  the  brain,  by  the  lungs,  or  by  the  heart.  Devergie  has 
included  in  the  category  of  those  who  died  from  cerebral 
congestion  all  the  drowned  in  whom  there  was  this  post- 
humous circulation,  and  yet  Devergie  was  a  scientific  man 
and  a  very  learned  and  conscientious  observer. 

PUTREFACTION  IN  DIFPERENT  MEDIA. 

When  putrefaction  takes  place  in  the  ground,  the  epider- 
mis becom.es  covered  with  blebs,  filled  with  bloody  serum, 
just  as  in  putrefaction  in  the  air  ;  then  the  epidermis  sepa- 
rates in  flakes  ;  the  grave-diggers  sometimes  think  that  they 
hear  a  noise  in  the  grave  three  weeks  after  burial ;  this  noise 
is  due  to  the  bursting  of  the  abdominal  wall  when  distended 
by  gas.  The  tension  of  the  gas  in  the  intestines  would  not 
in  itself  be  sufficient  to  lead  to  the  bursting  of  the  belly,  if 
the  micro-organisms  had  not  already  liquefied  the  tissues, 
and  so  diminished  their  resistance. 

When  the  body  putrefies  in  the  water,  the  first  green 
patch  which  appears  does  not  show  itself  in  the  region  of 
the  caecum,  as  it  does  when  the  body  putrefies  in  the  open 
air,  but  over  the  sternum  ;  I  cannot  explain  to  you  the  cause 
of  this  variation.  It  is  much  more  important  to  know  that, 
in  spite  of  the  difference  of  the  medium,  the  phenomena  of 
putrefaction,  as  far  as  the  production  of  gases  and  their 
order  of  succession  are  concerned,  are  nearly  the  same,  since 
these  phenomena  are  determined  by  what  takes  place  in  the 
intestines.  Only,  as  the  body  sooner  acquires  the  surround- 
ing temperature  in  the  water,  the  phenomena  of  putrefaction 
will  be  hastened  or  retarded  according  as  the  water  is  warm 
or  cold.  Devergie  was  accustomed  to  say  that  in  summer  a 
corpse  took  as  many  hours  to  putrefy  in  the  water  as  it  took 
days  in  the  open  air. 


PUTREFACTION  IN  DIFFERENT  'MEDIA.'  87 

Hofmann  estimates  that  putrefaction  is  twice  as  rapid  in 
air  as  in  water. 

It  may  be  conveniently  remarked  here  that  during  sub- 
mersion the  water  penetrates  abundantly  into  the  blood.* 
that  this  coagulates  but  little  or  not  at  all,  and  that  the 
phenomena  of  posthumous  circulation  are  found  at  their 
maximum  in  the  bodies  of  the  drowned  ;  also,  when  the 
bodies  of  the  drowned  are  withdrawn  from  the  water,  putre- 
faction takes  place  with  extreme  rapidity. 

Bodies  more  frequently  undergo  transformation  into  fatty 
matter  in  the  water  than  in  the  open  air  ;  this  transforma- 
tion is  sometimes  complete  by  the  end  of  five  or  six  months. 
If  it  had  remained  exposed  in  the  open  air,  the  corpse  might 
have  been  putrefied  before  so  long  a  time  had  elapsed  ;  if  it 
had  been  placed  in  the  earth,  it  would  be  necessary  to  take 
into  consideration  the  state  of  the  coffin  and  of  the  soil ; 
putrefaction  might  be  hastened  or  retarded  thereby.  In 
the  water  the  phenomena  of  putrefaction  follow  the  same 
evolutionary  course  as  those  of  fermentation  within  the 
intestines.  The  Fenayrou  case  affords  a  demonstration  of 
this.  A  druggist  named  Aubert  was  murdered  in  the 
country  by  a  husband  and  wife  of  the  name  of  Fenayrou, 
assisted  by  their  brother.  To  get  rid  of  the  corpse,  they 
threw  it  into  the  Seine,  after  having  enclosed  it  in  a  piece 
of  lead  pipe.  They  hoped  that  thus  it  would  stay  at  the 
bottom  of  the  water.  Three  days  afterwards  Aubert  floated, 
though  still  enclosed  in  the  lead  pipe. 

An  enormous  quantity  of  lead  would  have  been  requisite 
to  prevent  a  body  from  rising  to  the  surface  ;  the  only  means 
of  keeping  it  at  the  bottom  would  be  to  open  the  abdomen 
and  perforate  the  intestines  ;  in  this  way  the  gases  would 
escape  as  soon  as  they  are  produced. 

It  happens  often  enough.  Gentlemen,  that  the  medico- 
legal expert  is  called  upon  to  investigate  putrefaction  in 
bodies  that  have  been  thrown  into  a  privy  ;  the  bodies  of 
new-born  children  are  very  often  thus  met  with,  though  it 
would  be  scarcely  possible  to  find  records  of  seven  or  eight 
such  cases  in  adults. 

*  Brouarde]  and  Vibert,  An7i.  d'Hyg.,  3'^  serie,  tome  iv.,  p.  452. 


THE  SIGNS  OF  DEATH. 


When  the  privy  is  badly  ventilated,  and  the  air  is  only 
renewed  with  difficulty,  and  when  nothing  is  cast  in  except 
urine  and  fasces,  the  phenomena  of  putrefaction  go  on  slowly 
therein.  Bodies  buried  in  a  thick  layer  of  such  matter  are 
sometimes  taken  out,  at  the  end  of  five  or  six  months, 
intact,  without  presenting  any  sign  of  decomposition  what- 
ever ;  the  colonies  of  microbes  seem  to  have  been  failures ; 
these  facts  have  been  observed  especially  in  new-born 
infants.  But  when  a  good  current  of  air  passes  through 
the  cesspool,  and  plenty  of  water,  especially  soapy  water,  is 
thrown  in  ;  when  the  seat,  as  is  often  the  case  in  the  country, 
is  pierced  with  several  holes,  which  consequently  allow  a 
free  influx  of  air,  putrefaction  follows  the  same  course  as  in 
the  water  or  the  open  air.  Remember  this  fact  simply : 
that  in  certain  conditions  putrefaction  may  be  retarded, 
and  that  Tardieu  managed  to  detect  in  the  body  of  a  new- 
born child  that  had  lain  in  a  cesspool  for  three  months,  spots 
of  ecchymosis  on  the  pleura  and  pericardium,  spots  which 
have  been  called  '  Tardieu's  spots,'  and  which  prove,  ac- 
cording to  him,  that  death  took  place  by  suffocation.  The 
little  body  was  not  putrefied. 

CADAVERIC   ALKALOIDS. 

Gentlemen,  during  the  time  that  putrefaction  is  taking 
place,  a  certain  number  of  toxic  products — cadaveric  alka- 
loids— are  produced  in  the  interior  of  the  organism. 

The  first  medico-legal  researches  were  made  by  Selmi  of 
Boulogne,  with  regard  to  the  supposed  poisoning  of  a 
General.  The  medico-legal  expert  had  concluded  that  there 
had  been  poisoning  by  delphinine.  Selmi  repeated  the 
experiments,  and  found  that  it  was  sufficient  to  allow  meat 
to  putrefy  in  the  open  air  in  order  to  obtain  from  it  this 
supposed  delphinine.  He  pursued  his  investigations  and 
isolated  some  other  alkaloids ;  these  are  very  volatile,  and 
consequently  there  is  some  danger  that  they  may  be  absorbed 
in  respiration.  In  1872,  M.  Armand  Gautier,  studying  with 
quite  a  different  object,  and  merely  as  a  chemical  question, 
the  decomposition  of  albuminoid  matters,  had  already  shown 
that  that  decomposition  gave  rise  to  toxic  substances. 


PUTREFACTION.— CADAVERIC  ALKALOIDS.  89 

I  myself  witnessed  the  following  occurrence  in  conjunc- 
tion with  M.  Boutmy,  and  I  was  absolutely  ignorant  at  the 
time  of  M.  Arm.  Gautier's  experiments  : 

A  woman  who  sold  poultry  in  the  market,  having  a 
stuffed  hen-turkey  that  had  not  been  sold,  and  which  she 
feared  would  be  spoilt,  invited  her  friends  and  relations  to 
eat  it  with  her.  Twelve  persons  partook  of  that  repast, 
and  no  one  noticed  any  peculiar  smell  or  flavour  about  the 
turkey.  The  woman  herself,  who  had  not  eaten  more  than 
her  guests,  was  taken  ill  in  the  night  and  died.  Her  guests 
also  became  ill,  but  none  of  them  died. 

We  were  appointed  by  the  magistrate  to  make  an  in- 
vestigation. We  found  in  the  stuffing  inside  the  turkey  a 
product  analogous  to  conicine,  and  we  met  with  the  same 
product  in  the  viscera  of  the  dead  woman. 

I  repeat  that  this  woman  had  not  eaten  more  of  the 
turkey  than  the  rest,  but  at  the  autopsy  we  discovered  that 
the  kidneys  were  diseased,  and  unable  to  eliminate  the 
toxines. 

Those  alkaloids  which  are  found  in  the  body  after  death 
are  called  ptomaines ;  those  which  are  generated  in  the  body 
before  death  are  called  leucomaines,  and  have  been  described 
by  M.  Gautier. 

In  former  times,  Gentlemen,  when  people  were  taken  ill 
after  having  swallowed  any  articles  of  food,  the  cooking 
utensils  were  always  blamed  ;  the  copper  saucepans  were 
badly  tinned,  and  the  acetate  of  copper  set  at  liberty  during 
the  preparation  of  the  food  was  said  to  be  the  culpable 
agent. 

It  is  a  curious  fact  that  this  idea  of  poisoning  by  copper 
owes  its  origin  to  Jean  Jacques  Rousseau,  You  know  how 
fashionable  his  ideas  were  for  a  certain  period  ;  you  know 
the  infatuation  they  created.  It  is  not  very  wonderful, 
therefore,  that  the  opinions  he  professed  on  the  injurious- 
ness  of  copper  should  have  gained  acceptance.  Neverthe- 
less, it  has  been  forgotten  that  the  ancients  did  their  cooking 
in  copper  vessels.  The  tinning  of  copper  saucepans  was 
only  introduced,  into  the  West  of  Europe  at  any  rate,  by 
the  gipsies,  who  were  the  first  to  line  the  interior  of  copper 


90  THE  SIGNS  OF  DEATH. 

vessels  with  tin  more  or  less  pure.  Lastly,  at  all  times, 
and  even  to-day,  certain  culinary  preparations  are  only 
made  in  untinned  pans.  Such  is  the  case  with  preserves, 
which  have  never  poisoned  anybody  yet,  and  yet  which  are 
capable — for  example,  when  preserves  of  currants  are  being 
made — of  producing  soluble  salts  of  copper. 

We  know  now  that  copper  utensils  are  quite  harmless  so 
long  as  they  are  kept  in  good  order. 

When  the  writings  of  MM.  Selmi,  Armand  Gautier, 
Boutmy,  and  myself,  had  been  published,*  a  German 
named  Brieger  made  a  very  complete  study  of  ptomaines. 
He  divided  them  into  tv/o  classes  :  the  first  in  which  neurine 
predominates,  and  whose  action  is  convulsive  ;  the  second 
in  which  other  substances  are  more  abundant,  and  which 
have  a  narcotic  action. 

The  important  point  to  remember  about  this  classification 
is  that  certain  ptomaines  come  into  existence  at  the  same 
time  that  the  inflammable  gases  of  which  I  was  lately 
speaking  to  you  are  formed,  and  that  these  ptomaines  pro- 
duce exactly  the  same  effects  as  strychnine  and  its  salts. 
This  identity  may  become  a  source  of  fallacy,  against  which 
you  ought  to  be  on  your  guard. 

A  second  point,  not  less  important  to  grasp,  is  that  cer- 
tain toxic  alkaloids,  to  which  M.  Gautier  has  given  the  name 
of  leucomaines,  may  be  developed  during  life  in  the  course 
of  certain  maladies.     Here  are  some  examples  : 

In  1881,  when  the  cholera  epidemic  raged  in  Paris,  M. 
Gabriel  Pouchet  had  arranged  a  series  of  experiments  on 
the  urine  and  dejecta  of  cholera  patients.  He  had  suc- 
ceeded in  extracting  from  these  organic  substances  a  certain 
number  of  alkaloids,  which  Vulpian  brought  before  the 
Institute  in  his  name.  At  the  very  moment  when  M.  Pouchet 
had  enclosed  the  products  of  his  experiments  in  hermetically 
sealed  tubes  to  be  forwarded  to  Vulpian,  he  himself  felt 
indisposed,  and  became  very  ill.     He  had  dilatation  of  the 

*  Brouardel  and  Boutmy,  '  Sur  le  Developpement  des  Alcaloides 
cadavdriques,  Ptomaines'  iAnn.d^Hyg.,  1880)  ;  'Des  Ptomaines,  Reactif 
propre  a  les  distinguer  des  Alcaloides  vegetaux'  {A?ifi.  d' Hyg.,  1880)  ; 
'  Conditions  du  Developpement  des  Ptomaines'  {Ann.  d'Hyg.,  1881). 


PUTREFACTION.— CADAVERIC  ALKALOIDS.  91 

pupils,  suppression  of  urine,  aphonia,  cramps  in  the  ex- 
tremities, and,  in  a  word,  all  the  symptoms  of  cholera 
except  vomiting  and  diarrhoea.  He  had  been  poisoned  by 
the  products  manufactured  in  his  own  laboratory  by  those 
alkaloids  which  he  had  isolated,  and  which  are  very  volatile, 
and  not  by  any  substances  developed  in  the  intestines. 
When  he  became  convalescent  he  had  albuminuria  and 
glycosuria,  just  like  patients  recovering  from  cholera. 

This  is  not  the  whole  of  the  story.  Gentlemen,  for  when 
M.  Pouchet  returned  to  his  laboratory,  he  asked  what  had 
become  of  his  assistant  and  laboratory  servant.  He  was 
told  that  both  had  been  suffering  from  the  same  sort  of 
illness  that  he  had.  Like  him,  they  had  been  poisoned  by 
the  extremely  volatile  products  extracted  from  cholera 
dejecta. 

There  exists  a  certain  class  of  lunatics,  those  who  suffer 
from  melancholia,  who  scarcely  ever  have  their  bowels 
moved  ;  their  temperature  is  subnormal,  their  extremities 
cyanotic,  and  their  life  extremely  sluggish,  almost  vegetative. 
Their  urine  contains  a  considerable  quantity  of  alkaloids. 

I  will  not  pursue  this  subject  further.  Gentlemen  ;  I  only 
want  you  to  appreciate  that  there  is  from  the  point  of  view 
of  the  future  study  of  mental  alienation  a  very  interesting 
suggestion  contained  herein,  which  you  will  do  well  to  bear 
in  mind,  and  even  to  grasp  thoroughly. 

Here  is  another  case.  A  druggist,  who  does  not  wish  his 
name  to  be  made  public,  married.  During  his  wedding 
night,  his  young  wife  had  an  epileptic  seizure  :  the  attacks 
recurred.  The  husband  analysed  his  wife's  urine  before, 
during  and  after  the  attacks ;  when  the  attack  was  coming 
on,  the  urine  always  contained  an  enormous  quantity  of 
ptomaines  or  leucomaines. 

Finally,  Gentlemen,  the  existence  of  these  alkaloids  has 
been  demonstrated  in  various  kinds  of  spirits,  and  not  only 
in  those  spirits  derived  from  grain,  potatoes,  etc.,  whose 
quality  leaves  something  to  be  desired,  but  even  in  brandy 
distilled  from  fruit  or  grapes.  You  have  heard  mention 
made  more  than  once  in  medical  jurisprudence  of  cases  of 
poisoning  by  ingestion  of  pork  in  various  forms  or  of  tainted 


92  THE  SIGNS  OF  DEATH. 

meat.  There  is  something  peculiar  about  these  fatalities : 
wherever  they  have  been  observed,  whether  in  France, 
England,  Austria,  Belgium,  Germany,  etc.,  they  take  place 
chiefly  from  April  15th  to  June  ist,  and  from  September  ist 
to  October  12th. 

How  is  the  production  of  these  accidents  to  be  explained  ? 
In  certain  towns  of  the  North,  the  working  classes  are  accus- 
tomed to  eat  at  their  evening  meal  meat  in  the  form  of 
sausage  spread  on  bread.  One  day  at  Lille  seventy  persons 
fell  ill,  and  seven  or  eight  of  them  died,  after  having  eaten 
some  pork  that  was  all  bought  at  the  same  pork-butcher's. 
The  symptoms  observed  resembled  those  of  cholera. 

Being  sent  to  Lille  on  a  commission  of  inquiry,  I  noted  in 
all  the  patients  whom  I  visited — and  there  were  about  fifty 
of  them — dilatation  of  the  pupils,  headache,  some  digestive 
derangement  and  extreme  prostration.  The  investigation 
revealed  the  following  facts  :  Two  pork-butchers  had  piir- 
chased  a  pig,  but  whereas  the  customers  of  one  all  fell  ill  after 
eating  sausages  made  of  the  flesh  of  one  half  of  the  carcass, 
the  customers  of  the  other  remained  absolutely  free  from 
anything  of  the  sort.  It  could  not  therefore  be  the  previous 
condition  of  the  pig  that  was  to  blame  ;  the  shop,  the  stall, 
and  the  workshop  of  the  butcher  were  clean  and  in  good 
order.  It  was  necessary  to  search  further.  The  pig  had 
been  killed  on  a  Friday,  a  day  on  which  the  pork-butchers' 
shops  are  closed  at  Lille.  The  meat  had  been  exposed  for 
sale  on  Saturday,  May  igth,  and  Sunday,  May  20th,  and 
none  of  the  buyers  suffered  at  all.  Those,  however,  who 
bought  sausages  on  Monday  and  Tuesday  (May  21st  and 
22nd)  were  all  taken  ill,  and  four  of  them  died.  The  law 
interfered,  and  the  sausage-meat  was  withdrawn  from  sale 
on  the  Wednesday.  On  that  day  and  the  day  following  the 
pork-butcher,  not  wishing  to  lose  his  goods,  fed  himself  and 
his  household  on  the  remains  of  the  pork,  and  no  mishap 
followed. 

We  find  identical  facts  in  a  case  related  by  an  Irish 
physician;  instead  of  sausage-meat,  pork-pies  were  in 
question,  but  the  events  occurred  in  absolutely  the  same 
fashion. 


PUTREFACTION.— CADAVERIC  ALKALOIDS.  93 

The  fact  is,  Gentlemen,  that  the  toxic  alkaloids  only  exist 
for  one  or  two  days  (they  were  not  as  yet  formed  on  the 
Saturday  and  Sunday,  and  had  quite  disappeared  on  the 
Wednesday  and  Thursday)  ;  there  is  a  temporary  virulence; 
they  in  no  way  modify  the  odour  or  aspect  of  the  meat,  and 
nothing  can  reveal  to  the  inspector  the  existence  of  any 
fermentation. 

Facts  like  those  which  took  place  at  Lille  are  not  rare, 
and  epidemics  caused  by  ptomaine-poisoning,  which  have 
lasted  only  a  week  or  ten  days,  have  been  described  more 
than  once  under  the  name  of  epidemics  of  cholera  or 
typhoid  fever. 

These  alkaloids  may  be  produced  before  death  in  animals 
as  well  as  in  man.  H.  Bouley  brought  this  fact  to  light 
some  years  ago  in  a  medico-legal  report.  The  question 
arose  in  a  case  in  which  a  butcher  was  accused  of  having 
poisoned  several  people  to  whom  he  had  sold  the  meat  of 
a  heifer  which  had  formerly  been  in  an  unhealthy  condi- 
tion. The  facts  were  that  the  butcher  had  bought  a  heifer  ; 
it  escaped,  had  been  chased,  and  died,  having  been  over- 
driven by  dogs.  The  butcher  cut  up  the  carcass,  and 
twenty  or  thirty  of  his  customers  who  bought  portions  of  it 
fell  ill.  There  had  been  a  production  of  toxic  alkaloids 
during  life,  by  means  of  the  overwork  and  exhaustion  of  the 
beast. 

From  the  point  of  view  with  which  forensic  medicine  is 
concerned,  the  detection  of  these  alkaloids  is  extremely 
difficult.  It  is  actually  very  difficult  to  be  quite  certain 
whether  the  poison  that  we  discover  is  one  that  has  been 
administered  with  the  intention  of  killing,  or  a  ptomaine 
that  has  been  developed  in  the  course  of  putrefaction.  You 
shall  judge  for  yourselves  by  the  following  case  :  A  merchant 
of  stout  build,  who  lived  in  Paris,  bought  some  colchicine  ; 
his  wife  died  shortly  afterwards  ;  a  foreman  who  had  bought 
the  colchicine  on  his  employer's  behalf  let  it  be  known  that 
he  had  done  so,  and  people  began  to  chatter;  the  coinci- 
dence appeared  all  the  more  striking  inasmuch  as  the 
widower  started  on  a  journey  soon  after  the  burial  of  his 
wife,    taking   with    him    the   chief    female    assistant    in   his 


94  THE  SIGNS  OF  DEATH. 

shop.     The  law  was  set  in  motion,  and  the  body  was  ordered 
to  be  exhumed. 

MM.  Gabriel  Pouchet,  Ogier,  and  I*  were  charged  with 
the  investigation.  You  know  that  the  tests  for  colchicine 
are  colour  tests ;  those  which  we  obtained  in  this  case  were 
distinctly  those  of  colchicine,  but  we  did  not  dare  to  con- 
clude that  poisoning  had  taken  place,  because  we  were  afraid 
that  the  reactions  of  ptomaines,  which  we  did  not  know 
much  about,  might  be  identical,  and  their  presence  in  the 
viscera  was  possible. 

A  fresh  inquiry  was  ordered,  and  M.  Schutzenberger  was 
appointed  to  join  us.  We  had  onh-  used  one  half  of  the 
viscera  of  Mme.  X.  in  our  previous  analysis.  The  other  half 
had  been  placed  in  jars  and  carefully  preserved.  At  the 
time  of  the  first  investigation  we  had  had  taken  to  the 
Morgue  the  viscera  of  a  body  which  had  died  about  the 
same  time  as  Mme.  X. ;  these  were  preserved  in  jars  also. 
We  started  afresh  with  our  analysis,  first  on  the  viscera  of 
Mme.  X.  which  remained,  then  on  those  of  the  other  body 
at  the  Morgue,  as  a  control  experiment.  The  colour  pheno- 
mena were  identical  in  both.  We  had  acted  quite  rightly, 
therefore,  in  reserving  our  conclusions,  and  in  not  affirming 
the  case  to  be  one  of  poisoning  by  colchicine,  although  we 
had  obtained  the  proper  colour  reactions. 

Also,  Gentlemen,  believe  what  I  say :  when,  in  the  course 
of  investigating  a  case,  a  chemist  brings  you  colour  reactions 
and  nothing  more,  to  demonstrate  the  presence  of  the  poison 
that  is  being  looked  for,  do  not  be  convinced  thereby ;  there 
exist  perhaps  a  thousand  ptomaines,  though  we  know  of  only 
a  dozen.  The  actual  state  of  our  knowledge  does  not  give 
us  the  right  to  be  positive  ;  it  rather  imposes  on  us  the  duty 
of  being  cautious. 

PUTREFACTION  OF  DIFFERENT  ORGANS. 

We  are  now  going  to  examine  the  progress  of  putre- 
faction in  particular  organs  : 

The  eye  undergoes  changes   that  are  very  important  to 

*  Brouardel,  'Accusation  d'Intoxication  par  la  Colchicine  :  Affaire  R., 
acquittement,  Relation  medico-legale  "  {Afui.  d^Hyg.,  i< 


PUTREFACTION  OF  DIFFERENT  ORGANS.  95 

know.  The  patch  on  the  sclerotic,  described  by  Larcher, 
which  I  have  already  mentioned  to  you,  appears  first;  then 
the  eyeball  shrinks ;  the  cornea  and  sclerotic  become 
wrinkled  ;  the  colour  of  the  iris  may  generally  be  distin- 
guished for  twelve  days  or  so  during  the  intermediate 
seasons  (spring  and  autumn)  ;  then  the  contents  of  the  eye 
escape  at  the  end  of  two  or  three  months.  This  last-men- 
tioned period  appears  to  me  somewhat  longer  than  is  gene- 
rally the  case. 

A  reddish  froth  escapes  from  the  mouth  and  nostrils, 
soiling  the  face.  We  have  already  spoken  of  the  green 
patch  which  appears  on  the  skin  over  the  region  of  the  iliac 
fossa,  and  the  bullge  of  sanious  reddish  fluid  into  which  the 
epidermis  is  raised.  In  putrefaction  in  the  open  air  the 
nails  become  loose  about  the  twentieth  da}-. 

"When  the  lungs  of  an  adult  begin  to  putrefy,  their 
anterior  and  lateral  surfaces  become  covered  with  blebs  of 
gas  ;  this  is  the  rule.  The  lungs  of  an  infant  which  has  not 
breathed  are  never  covered  with  blebs  of  gas  ;  putrefaction 
proceeds  in  them  quite  in  a  different  fashion  to  that  in 
adults  ;  it  seems  to  be  necessary  for  the  external  air,  or  the 
blood  of  the  intestines,  to  bring  the  germs  of  putrefaction 
into  the  alveoli  in  order  that  they  should  putrefy,  according 
to  the  rules  which  we  know. 

The  posterior  parts  of  the  lungs  are  the  seat  of  well- 
marked  hypostatic  congestion.  The  colouring  matter  of  the 
blood  invades  the  whole  parenchyma,  then  a  certain  quan- 
tity of  serum,  coloured  by  the  same  material,  is  effused  into 
the  pleural  cavities. 

The  ciliated  epithelium  of  the  trachea  retains  its  vibratile 
movements  for  twenty-six  to  thirty  hours  (Gosselin). 

The  liver  changes  into  an  alveolar  mass  filled  with  gas  ; 
when  a  slice  of  it  is  thrown  into  water  it  floats  ;  that  is  the 
best  sign  of  advanced  decomposition.  If  then,  in  conduct- 
ing an  autopsy,  you  meet  with  a  liver  that  will  float,  you 
may  make  a  note  of  it,  and  conclude  therefrom  that  death 
must  have  taken  place  at  a  somewhat  remote  period. 

As  regards  the  brain,  the  progress  of  putrefaction  varies. 
In  adults  generally  it  takes  place  slowly;  in  the  foetus  and 


96  THE  SIGNS  OF  DEATH. 

newly-born  child  it  is  more  rapid,  perhaps  because  the  viscus 
contains  more  water ;  it  is  a  point  which  requires  elucida- 
tion. 

Of  all  the  organs,  the  uterus  putrefies  last  :  for  a  long  time 
after  death  its  examination  is  capable  of  affording  precise 
information.  Casper  relates  the  following  instance  :  The 
body  of  a  servant-girl,  i8  years  of  age,  was  found  at  the 
bottom  of  a  well.  She  was  buried,  but  after  more  than  a 
year  had  gone  by,  her  master  was  suspected  of  having  caused 
her  to  become  pregnant  and  thrown  her  into  the  well,  and 
he  was  arrested  in  consequence ;  however,  he  denied  it 
strenuously.  An  exhumation  was  ordered,  and  Casper  was 
appointed  to  undertake  the  investigation.  The  uterus 
eighteen  months  after  burial  had  still  the  shape  of  one  that 
had  never  been  impregnated.  The  accused  man  naturally 
was  acquitted. 

For  my  own  part,  I  have  had  to  perform  an  autopsy  on 
the  body  of  a  woman  who  had  been  buried  in  the  cemetery 
of  Ivry  sixteen  months  before.  A  midwife  v/as  charged  with 
having  neglected  to  give  the  woman  sufficient  care  and 
attention.  I  was  able  to  determine  the  measurements  of 
the  uterus,  and  found  them  to  be  6:^  inches  in  every  dimen- 
sion, which  was  the  proper  size  of  the  uterus  immediatelv 
after  delivery. 

When  medico-legal  examinations  have  to  be  made  at  a 
considerable  period  after  death,  it  is  a  good  plan  to  soak  the 
uterus  in  alcohol  for  some  days,  renewing  the  liquid  from 
time  to  time ;  by  this  means  the  tissues  become  decolorized 
and  their  consistence  firmer,  and  thus  the  existence  of 
lesions  may  be  determined  which  would  escape  notice 
without  this  precaution. 

The  bones  last  a  very  long  while ;  the  older  a  bone  is,  the 
lighter  it  becomes ;  it  loses  all  its  organic  matter ;  it  pre- 
serves its  form,  but  it  becomes  friable  and  its  weight 
diminishes. 

We  may  conclude  from  these  data  whether  the  bone  that 
we  are  examining  belongs  to  a  person  who  has  been  dead 
five,  ten,  or  twenty  years.  Remember  that  this  approximate 
calculation  can  scarcely  go  beyond  the  last  figure.     Some 


PUTREFACTION  OF  DIFFERENT  ORGANS.  97 

time  ago  I  made  experiments  on  this  subject  with  M.  Des- 
coust  on  skeletons  found  in  cellars  and  procured  from  bodies 
buried  after  the  events  of  May,  1871.  There  was  appreci- 
able loss  of  weight  in  these  bones.  These  experiments  have 
been  repeated  on  the  skeletons  of  animals  by  M.  Ad.  Carnot, 
Professor  in  the  School  of  Mines  ;  but  from  the  special  point 
of  view  which  occupies  our  attention  now,  in  spite  of  the 
curious  results  he  obtained  from  them,  and  has  recorded,  they 
cannot  be  turned  to  any  practical  use. 

PRESERVATION  OF  DEAD  BODIES. 

When  an  exhumation  is  officially  ordered,  in  cases  of  pre- 
sumed poisoning,  the  exhumed  body  may  be  in  a  perfect 
state  of  preservation ;  must  it  be  concluded,  as  is  too  often 
attempted,  that  the  presumption  of  poisoning  is  justified  ? 
Gentlemen,  there  are  cemeteries  which  destroy  and  ceme- 
teries which  preserve  :  in  the  first  the  bodies  are  rapidly  got 
rid  of;  the}^  are  preserved  for  an  indefinite  time  in  the  second. 
It  is  necessary,  in  a  medico-legal  report  on  an  exhumed 
body,  to  note  the  fact  of  preservation,  but  it  must  only  be 
considered  as  one  of  the  matters  to  be  inquired  into ;  when 
there  has  been  poisoning  by  arsenic,  preservation  of  the 
corpse  is  the  rule.  One  of  the  women  poisoned  by  Pel  was 
found,  four  years  after  death,  in  the  exact  condition  in  which 
she  was  when  put  into  her  coffin.* 

Another  point  which  is  quite  as  important  is  to  find  out 
the  nature  of  the  soil  of  the  cemetery ;  it  is  of  hygienic  as 
well  as  of  medico-legal  interest.  I  shall  not  say  very  much 
about  it. 

There  are  some  cemeteries  or  portions  of  cemeteries  in 
which  the  corpses  are  exceedingly  well  preserved.  Let  us 
just  consider  what  happens  in  the  case  of  ordinary  corpses 
placed  in  shells  made  of  deal  boards.  Buried  seventeen 
months  before  in  the  temporary  graves  of  the  cemetery  of 
Ivry,  these  bodies  had  all  the  soft  parts  completely  stripped 
from  the  bones.  Other  corpses,  placed  separately  in  deal 
coffins,  buried  in  a  very  damp  clay  soil,  the  clay  of  which 

*  Brouardel  et  L'Hote,  'Affaire  Pel:  Accusation  d'Empoisonnement — 
Relation  medico-legale'  {Ann.  d' Hyg.,  1886). 

7 


THE  SIGNS  OF  DEATH. 


formed  a  thick  coating  over  the  whole  of  the  coffin,  were 
in  a  state  of  perfect  preservation  at  the  end  of  the  same 
period ;  the  soft  parts  remained,  but  transformed  into 
adipocere. 

We  know  that  gases  are  produced  during  the  destruction 
of  bodies.  It  had  been  inferred  that  these  gases  were 
dangerous  to  health ;  all  the  legislation  of  Prairial  relating 
to  cemeteries  is  based  on  that  theory.  It  was  a  matter  of 
serious  interest  to  determine  whether  it  was  true ;  it  was 
especially  with  regard  to  large  towns  that  these  pre- 
possessions arose.  A  commission  was  appointed  ;  I  took 
part  in  it  with  MM.  Carnot,  Ogier,  Schutzenberger  and  Du 
Mesnil.  We  contrived  numerous  experiments :  we  found 
that  the  gases  taken  at  the  surface  of  the  cemetery  are  in 
no  way  different  from  those  taken  elsewhere  under  the  same 
conditions  ;  beneath  the  surface  down  to  the  level  of  the 
coffin,  there  was  a  larger  quantity  of  carbonic  acid  than  at 
the  surface.  Whence  does  this  carbonic  acid  proceed  ?  Is 
it  from  the  decomposition  of  the  dead  bodies  ?  Perhaps, 
but  in  my  opinion  its  origin  is  much  more  general.* 

When  an  analysis  is  made  of  the  gases  of  the  soils  round 
populous  towns,  a  considerable  amount  of  carbonic  acid  is 
always  found  ;  when  pits  are  dug  in  these  soils,  these  rapidly 
become  filled  with  carbonic  acid,  whether  there  is  a  corpse 
at  the  bottom  or  not ;  lighted  candles  graduated  into  lengths 
of  20  inches  show  this  when  they  are  lowered  into  these 
pits.  Moreover  it  is  notorious  that  in  Paris  the  well-sinkers 
are  often  asphyxiated  by  the  carbonic  acid  which  is  given  off 
when  wells  are  being  sunk.  The  soil  is  saturated  with 
animal,  and  still  more  with  vegetable,  matter,  in  a  state  of 
decomposition,  and  yielding  carbonic  acid.  The  presence 
of  this  gas,  even  in  the  ground  of  a  cemetery,  proves 
nothing  ;  thus,  we  must  abandon  all  fear  of  danger  in  the  air 
arising  from  cemeteries.  I  believe  that  when  the  coffins  are 
placed  from  5  to  6|  feet  deep,  and  covered  with  earth,  the 
hydrogen  and  hydrocarbons  which  are  given  off  during 
decomposition  are  absorbed  by  that  thickness  of  earth  ;  at 

*  Brouardel  et  Du  Mesnil,  '  Des  Conditions  d'Inhumation  dans  les 
Cimetieres :  Reforme  du  D^cret  de  Prairial  sur  les  Sepultures '"  {Ann. 
d'Hyg.,  1892,  p.  27). 


PUTREFACTION.— PRESERVATION  OF  DEAD  BODIES.    99 

Marseilles,  where  the  subsoil  is  actual  rock,  so  that  it  is  im- 
possible to  dig  graves  more  than  20  inches  deep,  it  is 
necessary  to  cover  them  with  earth  and  raise  a  mound  over 
them,  in  order  to  ensure  the  conditions  necessary  for  the 
absorption  of  the  gases.  When  the  soil  is  very  loose,  and 
consists  of  very  warm  sand  like  that  of  Mauritius,  or  of  the 
desert,  bodies  are  preserved  by  being  mummified.  In  damp 
soils,  in  moist  clayey  earth,  putrefaction  is  not  complete  five 
years  after  burial  (and  that  is  important  from  the  point  of 
view^  of  the  re-occupation  of  the  space)  ;  the  tissues  have 
undergone  fatty  transformation,  and  have  become  adipocere, 
under  the  influence  of  the  wet  surroundings. 

We  must  not,  therefore,  infer  the  probability  of  poisoning 
from  the  preservation  of  the  corpse,  without  assuring  our- 
selves on  the  spot  as  to  the  preservative  powers  of  the 
cemetery,  and  that  all  the  bodies  buried  there  do  not  present 
the  same  characters,  or  that  no  portion  whatever  of  the 
cemetery  possesses  this  preservative  power.  Those  cemeteries 
whose  soils  have  preservative  properties  ought  to  be  made 
sanitary  ;  this  is  easily  accomplished  by  means  of  drains 
placed  at  intervals  of  3  or  4  yards  ;  it  is  a  curious  fact 
that  the  water  does  not  flow  away  by  these  drains,  but 
it  is  absorbed,  and  does  not  penetrate  deeply,  while  the  air 
circulates  freely ;  a  non-oxidizing  soil  is  replaced  by  a  soil 
which  allows  the  passage  of  abundance  of  oxygen.  The 
most  conclusive  instance  in  reference  to  this  matter  is  sup- 
plied by  the  cemetery  of  St.  Nazaire :  the  bodies  used  not 
to  be  destroyed ;  but  when  drains  were  laid  down,  imme- 
diately a  new  order  of  things  was  instituted,  and  by  the  end 
of  eight,  eleven  or  twelve  months,  the  corpses  had  undergone 
complete  destruction.* 

There  are  variations  in  the  rapidity  of  putrefaction ;  in 
Paris  it  is  the  usual  custom  to  throw  antiseptic  powders 
into  the  coffins,  such  as  sawdust  impregnated  with  carbolic 
acid,  nitro-benzene,  etc.  ;  the  commission  proved  that  the 
use  of  these  substances  prolonged  the  preservation  of  the 
bodies  greatly.      Impermeable   coffins  of  indiarubber  have 

*  Brouardel  et  Du  Mesnil,  '  Conditions  d'lnhumation  dans  les  Cime- 
tieres '  (Ann.  d' Hyg.,  1892,  tome  xxviii.,  p.  27). 


THE  SIGNS  OF  DEATH. 


been  invented  ;  at  the  end  of  two  years,  a  phthisical  woman, 

who  weighed  6gi  lb.  when  buried  in  one  of  these,  had  lost 
only  2^  lb.  in  weight. 

In  these  indiarubber  coffins,  also,  the  body  is  destroyed  in 
three  or  four  years,  and  there  is  formed  a  liquid  greasy  sub- 
stance, like  black  axle-grease,  which  rolls  about  in  the  coffin, 
and  when  the  coffin  is  opened  gives  forth  an  abominable 
stench. 

The  Commission  therefore  discountenanced,  as  far  as  the 
re-occupation  of  the  burial-ground  in  the  cemeteries  of  large 
towns  is  concerned,  the  addition  of  antiseptic  substances  and 
the  use  of  indiarubber  coffins.  It  is  a  fear  of  the  possibility 
of  contagion  that  has  given  rise  to  these  practices.  It  is 
quite  enough  to  have  the  coffin  firmly  closed,  and  to  make 
sure  that  no  organic  liquid  can  leak  out  of  it  during  its 
conveyance  from  the  house  of  the  deceased  to  the  cemetery. 
This  is  the  only  matter  of  importance,  and  the  result  is  easily 
attained  by  surrounding  the  body  with  a  layer  of  plain  saw- 
dust, without  the  addition  of  any  antiseptic. 

Moreover,  this  addition  of  corrosive  sublimate,  carboHc 
acid,  nitro-benzene,  etc.,  complicates  medico-legal  problems 
quite  unnecessarily.  These  substances  are  generally  impure, 
and  may  contain  a  variety  of  poisonous  principles  which  at 
the  time  of  disinterment  and  toxicological  analysis  might 
embarrass  the  most  competent  medical  jurist. 

The  process  of  putrefaction  in  lead  coffins  differs  from  that 
in  wooden  ones.  Lead  coffins  are  seldom  used  except  when 
it  is  required  to  transport  the  body  for  burial  a  long  distance 
from  the  place  where  decease  occurred,  or  where  the  relatives 
wish  to  make  a  display  of  luxury.  Metallic  coffins,  whether 
of  lead  or  zinc,  are  nearly  always  enclosed  in  an  oak  shell. 
If  one  of  these  coffins  is  opened  at  the  end  of  three  months, 
the  corpse  looks  as  if  it  were  in  a  bath  of  sweat ;  it  is  covered 
with  moisture,  and  the  skin  is  corrugated.  When  the  first 
aerobic  colonies  commence  their  work  of  destruction,  the 
coffin  is  filled  with  gases,  the  tension  of  which  may  become 
excessive,  so  as  to  make  the  metallic  lid  bulge,  and  even 
burst.  But  at  the  end  of  six  months  the  surface  of  the  lead 
is  depressed  instead  of  being  bulged  ;  the  increased  pressure 


PUTREFACTION.— PRESERVATION  OF  DEAD  BODIES.    loi 

within  has  given  place  to  diminished  pressure.  The  tension 
of  gases  in  the  first  periods  of  putrefaction  may  be  formid- 
able. 

An  English  actress  came  to  Paris  and  stayed  at  the  Grand 
Hotel;  then,  in  the  company  of  two  of  her  fellow- country- 
women and  her  maid,  she  went  one  day  for  a  walk  in  the 
Pre  Catalan,  and  drank  a  glass  of  milk  there.  Almost  imme- 
diately she  became  unwell,  and  was  taken  to  the  x\rmenon- 
ville  pavilion,  where  she  died.  Immediately  after  her  death, 
the  maid  returned  to  the  Grand  Hotel,  carrying  all  her 
mistress's  clothes  with  her,  and  sent  a  telegram  to  a  person- 
age of  high  social  position  in  London,  who  was  interested  in 
the  young  woman.  The  other  Englishwomen  remained  at 
the  Armenonville  pavilion  with  the  body,  totally  unable  to 
give  any  explanation  of  the  occurrence  (they  could  not  speak 
French),  and  the  superintendent  of  police  interfered.  He 
found  the  body  of  the  young  woman  stretched  on  a  bed, 
wearing  a  red  silk  chemise  ;  but  he  could  obtain  no  en- 
lightenment. 

He  decided  to  send  the  Englishwomen  to  the  police-station 
near  the  Bois  de  Boulogne,  and  the  body  to  the  ^lorgue.  It 
was  there  that  I  saw  the  body,  and  had  to  make  the  post- 
mortem examination.  I  may  add  that  the  personage  to  whom 
the  maid  had  telegraphed  arrived  at  the  very  moment  when 
I  was  beginning  the  autopsy,  and  before  the  Englishwomen 
had  left  the  police-station ;  he  had  therefore  made  great 
haste.  When  the  autopsy  was  finished  (I  will  not  say  here 
what  results  were  found),  the  body  was  placed  with  the 
separate  viscera  in  a  lead  coffin. 

It  was  late  in  the  day  ;  the  workman  may  not  have  had 
enough  time,  or  perhaps  he  had  not  received  precise  direc- 
tions. I  do  not  know  how  it  was,  but  at  any  rate  he  did  not 
enclose  the  metallic  coffin  in  one  of  oak.  In  the  night  the 
lead  coffin  exploded  from  the  pressure  of  gas  evolved  by  the 
first  colonies  ;  the  metal  was  extensively  split,  and  yet  the 
abdomen  and  intestines  had  been  opened. 

You  see,  then,  what  expansive  force  these  gases  may 
acquire. 

I  have  told  you  already  that  the  soil  of  a  cemetery  is  not 


THE  SIGNS  OF  DEATH. 


injurious  to  the  health  of  those  who  are  walking  about  on  it. 
It  is  highly  dangerous  to  the  grave-diggers,  who  are  surrounded 
by  an  atmosphere  of  carbonic  acid  while  digging  the  graves. 
But  the  danger  is  much  greater  still  when  it  is  necessary  to 
enter  one  of  those  sealed-up  vaults,  known  by  the  name  of 
'permanent  concessions,'  which  are  full  of  very  dangerous 
gases. 

When,  as  most  frequently  happens,  the  oak  coffin  is  placed 
in  the  vault  without  being  covered  with  earth,  the  decom- 
position of  the  body  causes  a  sort  of  black  grease  to  filter 
through  the  seams  of  the  coffin,  and  to  spread  over  the  stone 
slabs.  The  smell  is  much  more  infectious  than  that  disen- 
gaged by  coffins  buried  directly  in  the  earth. 

Gentlemen,  I  have  tried  to  present  to  you  an  exact  picture 
of  the  various  forms  that  putrefaction  takes,  according  to 
differences  of  medium  and  circumstance.  Well,  there  are 
other  influences  besides  which  elude  us,  the  causes  of  which 
we  cannot  explain.  Certain  diseases  hasten  putrefaction, 
others — notably  cancer — retard  it.  But  there  are  other 
things  more  singular  still.  When  several  individuals  die  at 
the  same  time,  in  the  same  accident,  and  are  buried  together, 
they  still  may  not  putrefy  in  the  same  manner. 

After  the  memorable  days  of  July,  1830,  some  National 
Guards  who  had  fallen  in  the  combat  were  buried  in  the 
Place  de  la  Bastille.  When  the  excavations  for  the  founda- 
tions of  the  Column  of  July  were  dug,  five  years  after,  their 
bodies  were  found.  Some  of  them  were  skeletons,  clothed 
with  remains  of  their  belts,  etc.  ;  others  were  still  in  such  a 
state  of  preservation  that  their  features  could  be  recognized. 
The  fact  cannot  be  explained  at  present.  All  sorts  of  hypo- 
theses are  possible.  We  may  assume  that  all  these  men  had 
not  the  same  species  of  micro-organisms  in  their  digestive 
tubes. 


LECTURE  VI. 
CREMATION. —MUMMIFICATION. 

CREMATION. 

Until  i88g,  burial  was  the  only  legal  means  of  disposal  of 
the  dead.  Since  then  we  have  enjoyed  a  wider  liberty:  we 
may  be  burnt  to  ashes  if  we  choose.  Certainly,  it  may  seem 
preferable  to  some  persons  to  be  oxidized  by  fire  after  death, 
instead  of  being  slowly  destroyed  underground  by  successive 
colonies  of  micro-organisms  and  '  labourers  of  Death  ';  but, 
from  the  medico-legal  point  of  view,  cremation  has  a  certain 
inconvenience.  When  there  is  a  presumption  of  poisoning, 
it  is  usually  only  at  the  end  of  three  or  four  weeks  that  ex- 
humation is  ordered.  If  the  body  of  the  person  suspected 
of  having  been  poisoned  has  been  burnt,  the  proof  of  the 
crime  has  vanished  for  ever. 

The  extra-Parliamentary  Commission  appointed  in  i88g 
to  study  this  question  of  cremation  does  not  seem  to  me  to 
have  thoroughly  comprehended  the  importance  of  this  objec- 
tion. On  the  other  hand,  it  was  much  struck  with  the  fact 
that  in  the  time  of  an  epidemic  cremation  might  render  the 
greatest  service  by  making  the  bodies  disappear  quickly,  and 
with  them  the  possibility  of  an  ulterior  contamination  of  the 
soil. 

I  am  obliged  to  make  these  reserves,  which  are  justified 
by  a  case  observed  by  Henri  Sainte-Clair  Deville.  When  this 
learned  chemist  was  Professor  and  Dean  of  the  Faculty  of 
Science  at  Besangon  (in  1854),  he  was  summoned  to  make 
a  medico-legal  investigation.  An  entire  family  had  died 
during  an  epidemic  of  cholera.     The  fact  seemed   strange, 


I04  THE  SIGNS  OF  DEATH. 

and  certain  rumours  were  flying  about,  so  the  public  prose- 
cutor ordered  the  six  members,  of  whom  the  family  consisted, 
to  be  exhumed,  and  M.  Sainte-Claire  Deville  was  entrusted 
with  the  chemical  analysis.  Four  out  of  the  six  had  suc- 
cumbed to  poisoning  by  arsenic,  and  this  happened  at  the 
height  of  the  cholera  epidemic.  The  murderer,  who  would 
inherit  the  property,  hoped  that  from  the  similarity  between 
the  symptoms  of  cholera  and  those  of  arsenic-poisoning  his 
crimes  would  thus  remain  unknown  for  ever.  If  those  bodies 
had  been  submitted  to  cremation,  the  toxicological  analysis 
would  have  been  impossible.  Another  consideration  also 
deserves  attention.  Suppose  that  a  person  has  been  wrongly 
suspected  of  administering  poison  to  someone.  If  the  sup- 
posed victim  has  been  buried,  it  will  be  possible  for  the  in- 
criminated person  to  establish  his  innocence.  If  the  body 
has  been  burnt,  it  will  be  impossible  for  him  to  remove  the 
stigma,  which  will  be  attached  to  him  all  his  life. 

The  Commission  decided,  in  order  partially  to  meet  these 
medico-legal  objections,  that  in  Paris  two  physicians  should 
be  appointed  to  visit  the  corpse  which  is  about  to  be  cre- 
mated, and  make  a  report.  What  will  these  two  physicians 
manage  to  see  ?  They  would  have  great  difficulty  in  recog- 
nizing poisoning  by  the  aspect  of  the  body.  If  they  are  in 
any  doubt,  they  may  make  an  autopsy.  An  autopsy. 
Gentlemen,  in  cases  of  poisoning,  often  reveals  nothing 
definite,  and  it  does  not  enable  us  to  form  a  positive  con- 
clusion. In  order  to  be  quite  certain,  they  will  be  obliged 
to  demand  a  toxicological  analysis.  This  analysis  will  take 
three  months,  and  during  those  three  months  the  relatives 
will  be  a  prey  to  suspicions  and  disquietude. 

There  is  here  a  real  social  danger,  and  I  should  reproach 
myself  if  I  did  not  lay  stress  upon  it,  especially  with  regard  to 
the  suspicions  which  may  weigh  indefinitely  on  an  innocent 
man,  incapable  henceforth  of  proving  his  innocence. 

EMBALMING. 

Only  two  words  on  a  practice  which  does  not  prevail  much 
amongst  us.  I  wish  to  speak  of  enibalniing.  If  this  procedure 
were  universal,  we  should  have  an  infinite  number  of  pre- 


MUMMIFICA  TION. 


served  bodies.  Medico-legal  investigations  in  cases  of 
poisoning  would  be  equally  at  fault.  The  regulations  pro- 
hibit, it  is  true,  the  use  in  these  operations  of  salts  of  arsenic, 
corrosive  sublimate,  etc.;  but  embalming  can  only  be  per- 
formed by  employing  toxic  substances.  The  regulations  also 
enjoin  that  a  phial  should  be  placed  by  the  side  of  the  body 
containing  the  same  substances  that  have  been  used  in  the 
process.  This  precaution,  which  is  intended  to  facilitate 
research  in  case  of  an  inquest,  is  good,  but  insufficient. 

I  am  not  speaking  to  you  of  the  preservation  of  bodies  by 
ice.  This  procedure,  which  has  found  an  application  in 
the  refrigerating  apparatus  of  the  Morgue,*  is  only  applicable 
in  Institutes  of  Pathological  Anatomy. 


MUMMIFICATION. 

Putrefaction,  which  is  the  usual  mode  by  which  the  body 
is  destroyed,  is  not  the  only  one.  In  certain  conditions  it 
may  become  mummified.  Mummification  was  designedly 
performed  by  the  Egyptians,  who  wrapped  the  bodies  with 
closely-applied  bandages,  impregnated  with  aromatic,  and 
probably  antiseptic,  substances.  These  mummies  are  very 
well  preserved.  You  have  seen  them  in  museums,  and 
perhaps  some  of  these  exhibitions  are  fortunate  enough  to 
possess  the  representative  of  a  dynasty  2,000  years  old  ! 

Besides  this  intentional  mummification,  there  exists  another 
which  is  more  common.  The  sandy  soils  of  hot  countries, 
Mauritius  for  example,  mummify  the  bodies  which  are 
deposited  in  them. 

Mummification  may  take  place  in  the  foetus,  in  adults, 
and  in  the  newly  born.  In  the  foetus  it  takes  place  when 
death  has  happened  while  the  foetus  is  still  in  iitero,  and 
the  membranes  are  intact.  It  may  then  remain  for  years 
in  the  uterus,  or  in  the  Fallopian  tubes,  or  in  the  pelvis  if 
the  gestation  is  extra-uterine.  Mummification  takes  place 
in  the  foetus  when  the  atmospheric  germs  have  no  access  to 
the  dead  body. 

*  Brouardel,  'Installation  d'Appareils  frigorifiques '  {Ann.  dUJ^'g., 
1879). 


io6  THE  SIGNS  OF  DEATH. 

Mummification  of  the  bodies  of  adults  is  somewhat  rare ; 
nevertheless,  some  cases  of  it  have  been  recorded. 

Five  or  six  years  ago  the  body  of  a  female  servant,  who 
had  disappeared  nine  months  before,  was  discovered  under 
a  closed  brick  outhouse  at  the  bottom  of  a  garden  belonging 
to  a  medical  man  living  in  the  suburbs  of  Nantes. 

M.  Audouard  was  commissioned  to  examine  the  body. 
The  skin  was  like  parchment,  shrivelled,  and  of  a  buff 
colour.  When  it  was  tapped  with  the  back  of  a  knife,  it 
resounded  like  cardboard.  The  body  had  become  very 
light.  M.  Audouard  found  also  that  the  skin  was  per- 
forated by  an  infinite  number  of  holes,  like  a  colander,  and 
that  dust  from  within  escaped  through  these  little  holes. 
He  sent  me  a  thigh  and  a  leg,  which  weighed  one-third  of 
the  normal,  as  is  the  rule  in  cases  of  mummification  of 
adult  bodies.  I  showed  the  fragments  of  the  body  which 
M.  Audouard  sent  me  to  M.  Megnin,  who  has  devoted  great 
attention  to  the  study  of  the  natural  history  of  the  '  labourers 
of  Death.'  M.  Megnin  was  enabled  to  determine  the  time 
at  which  the  woman  had  died,  and  the  conditions  under 
which  her  death  had  occurred.  How  did  this  female,  eighteen 
or  nineteen  years  of  age,  become  mummified  ?  M.  Audouard 
attributed  it  to  the  dryness  of  the  chamber  in  which  the 
body  had  been  placed,  the  time  at  which  death  had  occurred 
(early  in  the  summer),  and,  lastly,  to  the  layer  of  wheat 
and  oat  straw  under  which  the  body  had  been  buried, 
and  which  had  absorbed  all  the  moisture  of  the  body.  It 
is  quite  possible.  M.  Megnin  made  the  discovery  that  the 
body  had  been  devoured  by  mites,  which  had  somehow  or 
other  eaten  all  the  tissues  of  this  woman.  In  the  leg  and 
thigh,  which  were  in  my  possession,  there  remained  only 
the  aponeuroses  and  meshes  of  cellular  tissue.  All  the 
muscles  had  vanished.  The  dust  which  escaped  in  clouds 
from  the  perforations  in  the  skin  was  composed  of  the 
excretions  and  debris  of  the  antennae,  etc.,  of  the  mites. 

Mummification  of  adults  is  rare  in  our  climates.  When 
it  takes  place,  the  viscera  are  in  close  apposition  ;  they 
contain  no  gas,  and  the  clothes  are  intimately  united  to 
the  body.     In  those  cases  which  I  have  had  the  opportunity 


MUMMIFICATION.  109 


of  observing,  the  liver,  stomach,  and  intestines  v^ere  alT.he 
lutely  inseparable  from  the  stays  in  the  case  of  a  woman-, 
or  from  the  jacket  in  the  case  of  a  man. 

Chemical  analysis  has  shown  that  the  alkaloids  produced 
are  identical  with  those  observed  in  the  bodies  of  the 
drowned. 

When  a  mummified  body  is  found,  the  law  requires  the 
medical  jurist  to  determine  the  time  when  death  took  place. 
This  question  is  of  great  importance,  for  according  to  the 
answer  to  it  the  prosecuting  authorities  will  know  in  what 
direction  to  turn  their  attention. 

Some  years  ago  a  chimney  in  a  house  in  the  Rue  de 
Tournon  was  pulled  down  ;  the  mummified  body  of  a  newly- 
born  child  was  found  behind  the  chimney.  A  servant  was 
the  only  person  who  could  be  incriminated,  but  there  had 
been  a  succession  of  nurses  in  that  room,  and  the  precise 
settlement  of  the  period  of  death  was  the  only  means  by 
which  justice  could  fix  on  the  true  culprit.  I  then  remem- 
bered the  work  of  Dr.  Bergeret. 

Dr.  Bergeret  (of  Arbois)*  was  the  first  to  throw  some 
light  on  the  question  ;  he  has  an  extensive  knowledge  of 
entomology.  Being  entrusted  with  the  examination  of  a 
child's  body,  which  he  found  covered  with  larvae  of  insects 
and  scales,  he  declared  that  death  must  have  happened  two 
years  previously.  His  opinion  was  not  accepted  by  the 
representatives  of  the  law,  who  then  appealed  to  Tardieu. 
The  latter  sought  for  information  from  Alfred  Moquin- 
Tandon,  who  was  at  that  time  Professor  of  Natural  History 
in  the  Faculty  of  Medicine  of  Paris.  Moquin-Tandon  con- 
firmed Dr.  Bergeret's  report. 

In  the  Rue  de  Tournon  affair,  which  I  had  to  investigate 
in  1878,  I  asked  M.  Perier,  of  the  Museum,  to  lend  me  his 
assistance.  M.  Perier  sent  me  an  interesting  note  in  reply, 
but  informed  me  at  the  same  time  that  M.  Megnin  had 
made  a  special  study  of  the  fauna  of  the  dead  body,  and 
that  he  alone  could  enlighten  me  on  certain  points.  Since 
then  M.  Megnin  has  several  times  given  me  the  greatest 
assistance  in  preparing  my  reports. 

*  Bergeret,  'Infanticide,  Momification   naturelle  du   Cadavre'  {Ann. 
cVHyg.,  1855,  tome  iv.,  p.  442). 


io6  THE  SIGNS  OF  DEATH. 


T-rhe  body  of  a  child  seven  or  eight  years  of  age  was  found 
■in  a  soap-box  ;  how  long  ago  did  death  take  place  ?  It  was 
then  the  month  of  July.  M.  Megnin  proved,  by  studying 
the  succession  of  flies  and  larvae  which  were  found  among 
the  remains,  that  the  body  had  been  placed  in  the  soap-box 
in  the  second  half  of  February  of  the  preceding  year.  The 
mother,  who  suffered  from  phthisis,  was  accused,  and,  as 
she  felt  her  end  approaching,  confessed  voluntarily  that  the 
deed  had  happened  on  February  23rd.* 

You  remember  the  case  of  Elodie  Menetrez  at  Ville- 
momble.  A  young  girl  disappeared  in  suspicious  circum- 
stances ;  some  human  bones  were  discovered  in  a  bed  of 
tulips  ;  several  liliaceous  bulbs  were  found  by  the  side  of  the 
corpse.  As  the  bulbs  of  tulips  are  themselves  devoured  by 
insects,  I  begged  M.  Megnin  to  find  out  when  these  bulbs 
had  been  buried  in  the  ground ;  they  had  evidently  been  put 
there  at  the  same  time  as  the  human  remains  which  had 
been  discovered.  M.  Megnin,  without  knowing  any  details 
of  the  history  of  the  case,  affirmed  that  the  bulbs  had  been 
put  into  the  ground  at  the  beginning  of  March  in  the  pre- 
vious year,  and  this  was  quite  true  ;  in  the  first  days  of  the 
month  of  March  the  girl  had  been  to  her  solicitor  to  sign  an 
agreement,  and  the  following  day  she  disappeared. 

This  is  a  point  to  which  you  should  pay  particular  atten- 
tion, Gentlemen.  I  do  not  ask  you,  mind,  to  make  these 
observations  yourselves ;  I  should  not  do  so  any  more  my- 
self; only  a  first-class  entomologist  is  capable  of  giving  such 
good  guidance,  and  if  we  were  to  lose  M.  Megnin  to-day,  I 
should  not  know  how  to  find  anyone  easily  to  take  his  place. 

M.  Megninf  divides  the  work  of  the  '  labourers  of  Death  ' 
into  four  periods  :  in  the  first,  quaternary  compounds  are 
attacked  and  destroyed  ;  in  the  second,  fatty  substances  are 
attacked  ;  in  the  third,  the  soft  parts  are  liquefied  ;  lastly, 
in  the  fourth  period,  the  dried-up  mummy  is  filled  with 
mites. 

*  Brouardel,  '  De  la  Determination  de  I'Epoque  de  la  Mort  d'un 
Nouveau-ne  faite  a  I'Aide  de  la  Presence  aes  Acares  et  des  Chenilles 
d'Aglosses,  dans  un  Cadavre  momifie'  (Aw2.  tVHyg.,  1879). 

t  P.  Megnin,  'La  Fauna  des  Cadavres'  (' Encyclopedie  Leaute,' 
G.  Masson,  1894). 


MUMMIFICATION.  109 


The  first  period  lasts  about  three  or  four  months.  The 
body  is  then  invaded  by  numerous  larvae  of  diptera  of  the 
genera  Curtonevra,  CalHphora,  Liicilia,  and  Sarcophaga. 
Coffins  may  be  literally  crammed  with  them. 

The  second  period  has  likewise  a  duration  of  three  to  four 
months.  The  diptera  are  replaced  by  coleoptera,  such  as 
Dermestes,  Corynetes,  and  the  Lepidoptera  called  AglosscB. 

In  the  third  period,  which  lasts  from  four  to  eight  months, 
we  meet  with  the  larvae  of  little  diptera  of  the  genera  Phora 
and  Antonia,  and  coleoptera  such  as  Silpha,  Hister,  Saprinus. 
The  soft  parts  are  transformed  into  a  black  deliquium. 

The  fourth  period  is  that  of  the  Acari  :  these  colonies 
exist  as  parasites,  and  eat  whatever  the  others  have  left ; 
they  are  represented  by  Tyroglyphiis,  Uropoda,  Anthrenus,  etc. 
The  bodies  undergo  at  this  period,  which  varies  from  six  to 
twelve  months,  a  mummification  which  may  last  a  very  long 
time. 

The  seasons  have  a  definite  influence  on  the  production 
of  these  insects.  When  a  body  is  put  into  the  coffin  at  a 
time  when  there  are  no  flies  about,  i.e.,  from  November  to 
February,  you  will  not  find  any  of  them  in  the  coffin  ;  but 
when  there  are  flies  at  the  time  of  placing  in  the  coffin, 
they  are  certain  to  enter. 

The  study  of  the  animal  life  of  the  tomb  is  extremely 
interesting  and  instructive. 

Gentlemen,  corpses  exposed  to  the  air  or  improperly 
buried  are  sometimes  devoured  by  dogs,  wolves,  or  other 
carnivorous  animals ;  you  easily  recognize  this  by  the  marks 
of  their  bites. 

But  it  sometimes  happens  that  bodies,  especially  those  of 
newly-born  infants,  are  eaten  by  rats.  The  bites  of  rats  are 
sometimes  difficult  to  recognize.  They  always  attack  the 
parts  that  are  fat,  i.e.,  the  cheeks  and  heels ;  they  divide  the 
skin  in  a  straight  line,  which  often  has  the  appearance  of 
having  been  cut  with  a  knife ;  so  close  is  the  resemblance 
that  it  is  often  difficult  to  avoid  a  mistake.  Rats  will  make 
a  body  disappear  with  extraordinary  rapidity.  At  the 
Morgue,  before  refrigerating  apparatus  was  introduced,  the 
rats  used  to  devour  the  bodies  in  spite  of  every  precaution. 


THE  SIGNS  OF  DEATH. 


In  submersion  in  the  sea,  crabs  attack  the  bodies,  choos- 
ing the  lobes  of  the  ears,  the  hps,  and  the  nostrils ;  and, 
according  to  the  climate,  other  animals,  such  as  carnivorous 
lish,  cause  mutilations,  the  nature  of  which  it  is  generally 
easy  to  determine. 

Do  not  forget  that  you  may  have,  in  cases  of  this  sort,  to 
form  a  differential  diagnosis  in  certain  circumstances. 

To  sum  up,  whatever  may  be  the  mode  of  destruction  of 
a  body,  there  is  always  a  fermentation  of  the  tissues,  a  pro- 
duction of  gas,  an  oxidation  that  is  more  or  less  rapid, 
according  to  the  method  of  destruction  chosen,  which  lead 
to  the  return  of  the  organism  to  the  mineral  kingdom  ; 
furthermore,  except  in  cremation,  the  intervention  of  suc- 
cessive colonies  of  insects  is  absolutely  necessary  in  order 
that  the  destruction  shall  be  complete. 


LECTURE  VII. 

LEGISLATION.— MEDICO-LEGAL  APPLICATIONS. 

Gentlemen, — In  order  to  complete  the  subject  of  death 
from  the  medico-legal  standpoint,  it  remains  for  me  to  enter 
with  you  upon  the  legislation  which  governs  the  matter. 
The  enactments  are  not  very  lengthy.  All  that  has  any 
concern  with  it  is  contained  in  certain  articles  of  the  Civil 
Code  (Art.  ']']  et  seq.),  and  of  the  Penal  Code  (Art.  35S 
et  seq.). 

Article  77  of  the  Civil  Code  is  thus  expressed : 
'No  interment  shall  be  made  without  the  authorization, 
on  unstamped  paper  and  free  of  cost,  of  the  registrar  of 
deaths  (officier  de  Vetat  civil),  who  shall  only  be  entitled  to 
give  it  after  visiting  the  deceased  person  to  assure  himself  of 
the  death,  and  only  twenty-four  hours  after  death,  except  in 
the  cases  provided  for  in  the  police  regulations.' 
Article  358  of  the  Penal  Code  is  thus  expressed  : 
'  Those  who  have  caused  a  deceased  person  to  be  buried 
without  the  previous  authorization  of  the  registrar  of  deaths 
in  the  cases  wherein  it  is  prescribed,  shall  be  punished 
by  imprisonment  of  six  days  to  one  month  and  a  fine 
of  sixteen  to  fifty  francs,  without  prejudice  to  the  prosecu- 
tion for  those  crimes  to  which  the  authors  may  have  made 
themselves  liable  at  the  same  time.  The  same  penalty 
shall  be  inflicted  on  those  who  have  contravened,  in  any 
manner  whatever,  the  law  and  the  regulations  dealing  with 
precipitate  interments.' 

The  legislator  has  imposed  on  the  registrar  of  deaths  the 


LEGISLATION. 


duty  of  verifying  the  death ;  the  office  is  held  by  the 
mayor  or  his  deputy.  In  the  36,000  communes  of  France, 
the  mayor  and  his  deputy  are  not  necessarily  doctors  of 
medicine ;  they  are  therefore  incompetent,  and,  as  they  are 
full}/  conscious  of  their  incompetence,  they  do  not  take  much 
trouble  about  it ;  they  do  not  go  to  the  deceased's  house  to 
obtain  actual  proof  of  death,  and  the  person  who  comes  to 
give  information  of  the  death  is  allowed  to  take  away  the 
permission  to  bury.  The  law,  such  as  it  is,  makes  this 
procedure  legal.  If  the  defunct  had  been  seen  during  life  by 
a  medical  man,  the  danger  would  not  be  so  very  great.  But 
in  the  country  many  people  die  without  any  professional 
man  being  called  in  at  all.  In  such  a  case  there  is  neither 
any  guarantee  nor  security.  What  is  the  period  fixed  by 
law  that  must  elapse  before  burial  ?  In  France  it  is  twenty- 
four  hours,  and  in  Paris  it  is  reckoned  from  the  moment 
when  the  declaration  of  decease  is  made  to  the  registrar  of 
deaths,  by  virtue  of  an  order  made  by  Frochot  in  1805. 
Frochot  remembered  the  well-known  verses  of  Moliere  : 

'He  who  buries  too  soon  often  commits  a  murder, 
And  a  man  is  believed  to  be  dead  who  has  only  the  appearance  of  it.' 

At  an}/  rate,  the  delay  imposes  a  check  on  innkeepers  and 
hotel  proprietors,  who  do  not  care  to  keep  a  corpse  in  their 
houses  for  long  ;  it  is  contrary  also  to  the  customs  of  the 
South  of  France,  where,  by  reason  of  the  high  temperature, 
it  is  desirable  to  bury  the  dead  as  quickly  as  possible. 

In  Germany  the  obligatory  time  to  wait  is  forty-eight 
hours,  in  Spain  and  Portugal  five  or  six  hours,  which  has 
made  a  witty  writer  say  that  a  man  must  not  sleep  too  long 
in  those  countries,  for  fear  of  being  put  under  the  earth. 
In  England  it  is  the  custom  to  wait  till  putrefaction  sets 
in,  thus  remaining  faithful  to  the  traditions  of  Greece  and 
Rome,  where  six  to  eleven  days  were  allowed  to  elapse 
between  death  and  the  funeral. 

The  mean  adopted  in  France  is  good  ;  it  is  long  enough, 
especially  when  death  occurs  in  small,  overcrowded  lodgings. 
It  is  impossible  to  keep  the  corpse  there  long,  partly  because 
of  the  smell  it  gives  off,  also  because  promiscuity  with 
death  rapidly  removes  the  respect  for  it. 


MEDICO-LEGAL  APPLICATIONS.  113 

Nevertheless,  we  have  been  obliged  in  France  to  make 
some  exceptions  to  this  rule  of  twenty-four  hours  ;  not  in 
order  to  lengthen  it,  but,  on  the  contrary,  to  shorten  it. 
When  an  epidemic  is  prevailing,  and  when  putrefaction  sets 
in  very  early,  the  mayor  may  shorten  the  obligatory  period 
of  waiting.  Thus,  in  1884,  when  cholera  was  epidemic  in 
Paris,  the  prefect  of  police,  after  having  consulted  with  the 
Council  of  Health,  issued  a  public  notice  recommending 
every  physician  attending  a  case  to  give  notice  himself  or 
to  get  the  family  to  give  notice  to  the  mayor  of  the  district 
of  every  death  from  cholera  that  took  place  in  his  practice ; 
a  man  was  then  sent  immediately  with  a  coffin  ;  the  public 
medical  verifier  of  deaths,  who  had  also  been  notified,  con- 
firmed the  fact  of  death,  and  the  compulsory  delay  might 
thus  be  safely  reduced,  since  two  medical  men,  the  one  in 
attendance,  and  the  pubHc  verifier,  had  both  ascertained  the 
reality  of  death.  The  public  verifier  could  always  obtain  a  pro- 
longation of  the  normal  period  of  delay.*  M.  Tourdes  is  of 
opinion  that  the  period  of  waiting  should  be  extended  from 
twenty-four  to  thirty-six  hours ;  this  does  not  remove  all 
uncertainty  ;  the  danger  does  not  lie  in  the  period  of  time 
fixed  by  law,  but  in  the  incompetence  of  the  persons  ap- 
pointed to  legally  confirm  the  fact  of  death. 

We  ask  in  France,  and  our  neighbours  in  Germany  have 
been  demanding  the  same  thing  since  1846,  that  all  deaths 
should  be  verified  by  medical  men  ;  we  have  in  France 
36,000  communes,  29,000  of  which  possess  neither  a  physi- 
cian nor  a  medical  officer  of  health  {ojficier  de  sante).  Can 
the  duties  therefore  be  placed  in  the  hands  of  the  medical 
officers  of  the  cantons  ?  One-sixth  of  the  cantons  of  France 
have  neither  a  physician  nor  a  medical  officer  of  health  ! 
It  therefore  seems  impossible  to  carry  out  the  law ;  though 
this   could    easily  be  rectified   by  taking  advantage  of  the 

*  The  decree  of  April  27,  1889,  made  these  regulations.  It  stipulates  : 
'  Art.  I . — The  registrar  of  deaths  may  in  an  urgent  case,  notably  in  a  case 
of  death  from  a  contagious  or  epidemic  disease,  or  in  case  of  rapid 
decomposition,  and  after  obtaining  the  opinion  of  a  medical  man,  order 
that  the  body  shall  be  placed  in  the  coffin  immediately  after  death  has 
been  officially  ascertained,  without  aff'ecting  the  right  to  order  the  burial 
without  the  delay  appointed  by  Art.  77  of  the  Civil  Code.' 

8 


114  LEGISLATION. 


organization  which  is  about  to  be  created  in  order  to  carry 
into  effect  the  law  referring  to  medical  assistance  in  the 
country.  When  the  question  of  the  verification  of  death 
was  discussed  at  the  Tribunate,  and  at  the  Council  of  State 
under  the  Empire,  Fourcroy  declared  that  the  registrar  of 
deaths  appeared  to  him  to  be  absolutely  incompetent  to 
fulfil  the  duties  of  verifier.  He  was  told  in  reply  that,  as  he 
had  the  responsibility,  he  would  take  care  to  be  accom- 
panied by  a  medical  man,  if  he  thought  proper.  It  is  not 
desirable  for  medical  men  to  be  assigned  duties  in  this  way 
which  belong  to  them  by  right. 

The  difficulty  has  been  overcome  in  large  towns  by  a 
simple  procedure.  In  Paris,  for  example,  there  is  in  each 
quarter  a  medical  verifier,  entrusted  with  ascertaining  the 
reality  of  every  death  in  his  division.  A  certain  number  of 
medical  inspectors,  placed  hierarchically  over  the  verifiers, 
are  retained  to  ascertain  the  reality  of  death  in  one  case  out 
of  every  three.  This  organization  exists  in  many  French 
towns.  It  abolishes  almost  entirely  the  risk  of  premature 
burial ;  but  in  the  country,  in  isolated  communes,  in  hamlets 
and  farms  when  there  has  been  neither  a  medical  man  in 
attendance  nor  another  to  verify  death,  accidents  may 
happen  like  that  related  by  Dr.  Roger  of  Morlaix,  and 
which  I  have  already  related  to  you  when  we  were  engaged 
in  the  study  of  the  signs  of  death  (v.  p.  37). 

I  only  know  one  way  of  avoiding  the  recurrence  of  such 
accidents,  viz.,  to  enforce  by  law  that  the  verification  of  death 
should  always  be  performed  by  a  medical  man,  who  would 
make  a  diagnosis  of  death  just  as  he  would  make  one  in  the 
case  of  pneumonia  or  typhoid  fever.  If  anyone  offers  as  an 
objection  the  paucity  of  medical  men  in  the  country,  I  will 
say:  'Add  the  duty  of  verification  of  death  to  the  other 
functions  of  medical  assistance  in  country  places  in  the  law 
that  is  now  under  discussion.  If  in  Lozere,  for  example, 
one-third  of  the  cantons  have  neither  a  physician,  medical 
officer  of  health,  nor  apothecary,  it  is  because  persons  be- 
longing to  these  professions  cannot  gain  a  livelihood  there. 
If  you  are  really  desirous  of  helping  the  indigent  population, 
organize  the  medical  service  in  such  a  way  that  the  medical 


MEDICO-LEGAL  APPLICATIONS.  115 

officers  may  make  a  living.  Nothing  is  more  easy  under 
those  conditions  than  to  entrust  to  them  the  dut}^  of  verify- 
ing deaths  also.  Do  you  complain  that  there  are  not 
enough  medical  men  to  do  the  work?  You  would  have 
plenty  the  very  day  that  you  would  assure  them  of  a  liveli- 
hood and  remunerate  them  for  their  services.' 

In  order  that  burial  may  take  place,  it  is  necessary  to 
show  the  written  permission  at  the  church  and  at  the 
cemetery.  This  permission  is  given  on  an  unstamped  sheet 
of  paper  by  the  registrar  of  deaths,  after  the  reality  of  death 
has  been  ascertained  ;  burial  cannot  be  proceeded  with  in 
the  absence  of  such  permission  without  committing  a  breach 
of  the  law. 

In  the  case  of  the  death  of  an  adult,  the  registrar  ought  to 
put  at  the  head  of  the  permit  '  Declaration  of  Death  ';  in  the 
case  of  a  new-born  child,  on  the  contrary,  he  says  that  a 
'  child  without  life '  has  been  reported  to  him  ;  it  is  for  the 
heirs  of  that  child  to  prove  that  it  has  lived,  if  there  is  any 
question  of  the  inheritance  of  property. 

Until  1881,  foetuses  expelled  prematurely  by  abortion  were 
thrown  into  privies,  dustbins,  drains,  or  on  to  dunghills. 

In  1864,  Tardieu  showed,  in  an  excellent  report,*  how 
immoral  it  was  for  such  a  state  of  things  to  exist. 

In  1881,  M.  Floquet,  then  Prefect  of  the  Seine,  issued  an 
order  prescribing  that  the  death  of  a  foetus  should  be  declared, 
and  that  it  should  be  buried ;  several  events,  both  in  Paris 
and  the  provinces,  had  called  for  this  administrative  measure. 

At  Provins,  in  1880,  a  foetus  was  found  on  a  dungheap  ; 
public  opinion  accused  a  girl  of  having  induced  abortion. 
At  the  very  moment  that  girl  was  being  married.  As  she 
was  actually  leaving  the  church,  the  deputy  to  the  public 
prosecutor,  acting  too  hastily,  caused  her  to  be  arrested  ; 
the  scandal  was  prodigious. 

An  investigation  took  place,  and  the  medico-legal  exam- 
ination proved  that  she  was  a  virgin.  The  deputy  was  dis- 
missed. 

*  Tardieu,  ^7tn.  d''Hyg.,  1864,  et  'Etude  medico-Iegale  sur  I'Avorie- 
ment,  suivie  d'une  Note  sur  I'Obligation  de  declarer  a  I'Etat  civil  les 
Fcetus  mort-nes,'  4''  ediiion.     Paris,  1881. 


Ii6  LEGISLATION. 


In  Paris  a  series  of  analogous  events  happened  :  tales  told 
b}'  neighbours,  and  charges  made  by  hall-porters,  led  to 
inquests  being  held,  whereby  the  falsity  of  such  stories  was 
proved. 

In  consideration  of  these  facts,  M.  Floquet  issued  the 
order  referred  to.  The  district  medical  officers  protested 
against  the  order  as  leading  to  violation  of  professional 
secrecy. 

Medical  secrecy  is  in  no  way  affected  by  M.  Floquet's 
order,  for  an  excellent  reason,  viz.,  because  the  matter  is  not 
a  secret  in  any  case.  The  order  obliges  the  foetus  to  be 
taken  to  the  mayor's  office,  in  the  same  manner  as  the  body 
of  a  new-born  child  would  be  taken  there  ;  but  just  as  a 
physician  may  say  when  he  is  begged  not  to  divulge  the  fact 
of  a  birth,  '  A  child  has  been  born  in  this  district  at  a 
certain  hour  of  a  certain  day,  of  father  and  mother  both 
unknown,  residence  unknown,'  so  he  is  permitted  to  declare 
with  the  same  reservations  that  a  foetus  has  been  born  on  a 
certain  day  in  his  district,  of  father  and  mother  unknown. 

A  box  has  been  placed  in  each  of  the  twenty  mayors' 
houses  in  Paris,  wherein  the  foetus  thus  declared  is  de- 
posited, and  whence  it  is  removed  by  the  men  whose  duty  it 
is  to  bury  it. 

Since  i88i,the  number  of  premature  confinements  declared, 
and  of  foetuses  thus  deposited,  has  steadily  increased  ;  from 
80  in  i88t,  it  reached  250  in  1893;  at  the  same  time  the 
number  deposited  in  privies  and  dungheaps  has  diminished 
in  the  same  ratio. 

The  opposition  to  the  decree  of  M.  Floquet  was  very 
strong.  The  opponents,  at  the  head  of  whom  was  M. 
Durand-Fardel,  senior,  medical  inspector  at  Vichy,  who 
published  an  extremely  spirited  memoir  on  the  subject, 
relied  especially  on  a  decision  of  the  Court  of  Appeal  of 
August  7,  1874.  It  declared  that  '  Art.  345  of  the  Penal 
Code  should  be  read  in  connexion  with  Art.  312  of  the  Civil 
Code,  by  the  terms  of  which  the  child  is  only  reputed  viable 
after  a  minimum  of  180  days  or  six  months  of  gestation ; 
that  the  being  which  comes  into  the  world  before  this 
period,  destitute  not  only  of  life,  but  of  the  organic  con- 


MEDICO-LEGAL  APPLICATIONS.  117 

ditions  indispensable  to  existence,  constitutes  merely  a 
nameless  object,  and  not  a  child  in  the  sense  which  a 
legislator  attaches  to  the  expression  ;  that  it  was  not  with 
the  idea  of  such  a  case  that  the  decree  of  July  3,  1806, 
ordered  that  the  body  of  every  new-born  child  should  be 
taken  to  the  registrar  of  deaths,  inasmuch  as  the  nearer  the 
time  of  its  coming  into  the  world  is  to  the  time  of  its  con- 
ception, the  less  does  it  present  the  distinctive  appearance 
of  a  human  being;  that  such  an  exhibition  would  be  without 
any  public  interest  or  utility,  and  might,  in  certain  cases, 
wound  the  public's  sense  of  decency.'  This  solution,  which 
has  been  admitted  by  several  courts  of  appeal  (Amiens, 
June  27,  1876  ;  Dijon,  May  11,  1879),  may  admit  of  criti- 
cism in  more  than  one  respect.  Without  inquiring  deeply 
whether  the  exhibition  of  the  product  of  an  abortion  might 
or  might  not  'wound  the  public's  sense  of  decency,'  and 
also  without  examining  whether  the  exhibition  would  be 
*  without  any  public  interest  or  utility,'  the  principal  argu- 
ment on  which  this  jurisprudence  is  founded  is  highly  con- 
testable from  a  judicial  point  of  view. 

For  my  part,  the  obligation  of  declaring  the  foetuses  is 
less  hurtful  to  the  public's  sense  of  decency  than  the  practice 
of  leaving  them  fully  exposed  on  a  dungheap  or  in  privies.* 

Innovations,  of  whatever  kind  they  may  be,  are  always  butts 
for  criticism  and  sources  of  recrimination.  It  is  the  same 
to-day  with  respect  to  the  law  which  renders  obligatory 
the  notification  of  contagious  diseases.  Meanwhile  no  one 
has  any  longer  any  idea  of  protesting  against  M.  Floquet's 
decree,  and  there  has  not  been  a  single  prosecution. 

*  Jurisprudence  011  this  point  has  varied  to  a  singular  degree.  Judg- 
ments have  decided  that  Art.  358  applies  to  unauthorized  burial,  what- 
ever period  gestation  may  have  reached,  provided  that  the  child  presents 
the  form  of  a  human  being  (Paris,  June  15,  1865  ;  Amiens,  December  20, 
1873  ;  Agen,  August  6,  1874.  See  also  Dijon,  December  16,  1868  ; 
Chambery,  February  29,  i868j. 

According  to  the  Court  of  Metz,  '  If  it  is  true  that  the  authorization 
of  the  registrar  of  deaths  is  not  essential  for  the  burial  of  a  simple  foetus  or 
embryo — z'.^.,  of  an  unorganized  being — it  is  not  permitted  that  private 
persons  shall  determine  the  limits  within  which  the  obligation  of  obtain- 
ing authorization  previous  to  burial  begins  and  ends.  This  duty  has 
been  imposed  by  law  on  a  public  man,  who  alone  has  the  right  of  deciding 
the  state  of  the  deceased  individual'  (Judgment  of  August  24,  1854). 


Ii8  LEGISLATION. 


All  the  medical  verifiers  have  noted  as  a  danger  at  the 
time  of  death  hasty  preparation  for  burial  when  the  deceased 
person  dies  at  his  own  home  in  the  midst  of  his  family.  It 
is  the  practice  under  such  circumstances,  due  to  the  fear  of 
not  being  able  to  enshroud  the  body  later,  when  rigor  mortis 
has  commenced.  You  know  that  the  attendants  shut  the 
dead  man's  eyes  and  mouth,  the  latter  by  means  of  a 
bandage,  that  the  face  is  covered  by  a  sheet,  and  that  the 
body  is  often  placed  too  soon  in  the  coffin,  etc.  This 
custom  constitutes  a  real  danger.  M.  Josat,  who  has  paid 
much  attention  to  questions  of  apparent  death  and  premature 
burial,  has  given  in  connexion  with  this  matter  a  very  happ}' 
formula  which  ought  to  be  remembered.  He  says  that  the 
dead  person  ought  to  be  presumed  to  be  alive  until  death 
has  been  verified,  and  that  he  ought  to  be  attended  to  care- 
fully until  this  is  done,  just  as  if  he  were  alive.  Casts  of 
the  body  can  only  be  taken  and  autopsies  made  twenty-four 
hours  after  the  fact  of  death  has  been  established  ;  the  mayor 
ought  to  receive  notice  of  an  autopsy  ;  he  is  bound  to  be 
present  or  to  be  represented  by  a  deputy.  In  Paris  this 
duty  devolves  upon  the  superintendent  of  police. 

What  I  have  just  said  applies  also  to  embalming.  I  have 
only  to  say  a  few  words  now  on  the  question  of  the  removal  of 
the  body.  Your  advice  will  often  be  sought  on  this  subject. 
When  a  body  has  to  be  conveyed  a  long  distance,  it  is  neces- 
sary to  have  a  metallic  coffin,  but  a  chest  composed  of  sheets 
of  zinc,  like  those  we  see  used  by  packers,  and  covered  with 
oak,  will  answer  in  the  majority  of  cases.  Lead  coffins  are 
very  expensive.  This  expense  of  transport  is  still  controlled 
in  France  by  a  series  of  old  legal  decisions,  which  are  not 
enforced,  however,  in  every  department.  They  belong  to 
that  group  of  laws,  having  hygiene  in  view,  which  are  only 
observed  in  a  department  where  the  prefect  makes  them 
compulsory.  The  authorization  of  such  a  practice  in  one 
department  does  not  imply  that  it  is  equally  so  in  the  next. 
However  strong  may  be  our  love  of  unity  in  France,  we  still 
have  to  deal  with  many  anomalies. 

If  the  body  has  to  be  removed  only  two  or  three  leagues, 
and  the  deceased  has  not  died  of  any  contagious  disease,  do 


MEDICO-LEGAL  APPLICATIONS.  119 

not  be  too  harsh  :  on  the  contrary,  when  the  journey  is  long, 
whether  death  is  from  a  contagious  disease  or  not,  you  must 
insist  on  the  employment  of  a  metallic  coffin,  covered  with 
an  oak  shell.  Remember  that  the  first  effect  of  putrefaction 
is  the  production  of  gases,  which  by  their  excessive  tension 
may  even  burst  a  metallic  coffin. 

What  conclusions  are  we  to  draw  from  this  long  study  ? 
A  physician  need  not  often  hesitate  over  the  diagnosis  of 
death ;  but  he  must  know  how  to  make  this  diagnosis,  just 
as  he  knows  how  to  make  that  of  typhoid  fever  or  meningitis. 
Some  cases  present  the  condition  of  apparent  death,  which 
may  be  more  or  less  prolonged.  The  physician  alone  is 
capable  of  making  the  diagnosis  in  these ;  everyone  else  is 
incompetent.  Also  we  are  convinced  that  if  the  verification 
of  death  were  everywhere  entrusted  to  medical  men,  the 
danger  of  premature  burial  would  be  almost  absolutely 
removed. 


PART  II. 
SUDDEN   DEATH. 

LECTURE  I. 
SUDDEN  DEATH. 

Gentlemen, — The  question  of  sudden  death  is  one  of  the 
most  important  in  forensic  medicine.  I  beg  that  you  will 
allow  me  to  speak  of  it  in  more  detail,  for  medical  men  are 
not,  generally  speaking,  in  favourable  conditions  to  become 
acquainted  with  all  the  numerous  causes  which  bring  it 
about. 

It  is  easy,  as  a  matter  of  fact,  to  study  the  diseases  of  the 
people  who  are  brought  to  the  hospital,  and  to  explain  satis- 
factorily the  morbid  conditions  to  which  they  succumb;  but 
when  an  individual  dies  suddenly  in  the  street  or  in  a 
house,  he  is  not  taken  to  the  hospital.  Generally  the  super- 
intendent of  pohce  is  informed  of  the  sudden  death,  and 
appoints  the  surgeon  attached  to  the  police-station  to  examine 
and  report  on  the  facts.  The  latter  ascertains  that  there  is 
no  mark  of  violence  on  the  body ;  he  puts  this  in  his  report 
quite  properly,  but  he  does  wrong  if  he  adds  that  death  is 
due  to  the  rupture  of  an  aneurysm  or  to  congestion  of  the 
brain.  He  cannot  actually  know  the  cause  of  death  of  the 
individual  whom  he  is  examining  ;  an  autopsy,  which  he  has 
not  made,  can  alone  tell  him  that,  and  even  then  an  autopsy 
will  not  enable  him  to  be  certain  sometimes.  Why,  then, 
should  he  pronounce  the  words  *  aneurysm  '  or  '  cerebral  con- 
gestion '  ?  Sudden  deaths  due  to  the  rupture  of  an  aneurysm 
are  so  rare  that  out  of  i,ooo  cases  observed  at  the  Morgue  by 


SUDDEN  DEATH. 


MM,  Descoust,  Vibert,  Socquet  and  myself,  we  have  only 
met  with  fatal  rupture  of  an  aneurysm  four  times  ;  as  to  cere- 
bral congestion,  such  a  thing  does  not  exist — at  least,  we 
have  never  met  with  it. 

What  is  the  proportion  of  sudden  deaths  among  medico- 
legal cases  ?  In  the  total  number  of  medico-legal  investiga- 
tions, cases  of  infanticide  and  of  sudden  death  are  almost 
equal ;  these  two  groups  together  constitute  two-thirds  of 
the  medico-legal  autopsies  made  in  France  annually. 

The  law  steps  in  when  death  takes  place  suddenly,  by 
virtue  of  Article  8i  of  the  Civil  Code  and  of  Article  44  of  the 
Code  of  Criminal  Proceedings.* 

This  is,  as  a  general  rule,  what  happens  in  these  affairs  : 
An  individual  dies  suddenly  (it  is  often  persons  of  advanced 
age,  from  50  to  70,  who  are  thus  struck  down) ;  death  has 
been  preceded  by  a  loss  of  consciousness  more  or  less  pro- 
longed, by  coma  or  by  vomiting,  which  suggests  the  idea  of 
poisoning  by  opium  in  the  one  case,  or  by  arsenic  in  the 
other.  The  dead  man  is  buried.  The  friends  of  the  deceased, 
as  they  are  following  the  funeral,  are  disturbed  by  the  thought 
that  they  themselves  may  also  be  carried  off  in  a  few  hours, 
and  begin  to  discuss  the  circumstances  in  which  the  deceased 
met  with  his  death.  Comments  are  made  very  freely.  If 
by  the  fact  of  the  death  someone  is  to  succeed  to  property, 
and  if  the  heir  should  be  a  man  in  embarrassed  circum- 
stances, to  whom  such  a  windfall  would  seem  an  unhoped- 
for stroke  of  good  fortune,  suppositions  become  more  defi- 

*  Cod.  Civ.,  81. — '  When  there  are  signs  or  indications  of  violent  death, 
or  of  other  circumstances  which  may  give  rise  to  suspicion,  burial  shall 
only  take  place  after  a  police  officer,  assisted  by  a  Doctor  of  Medicine 
or  of  Surgery,  has  drawn  up  a  written  report  of  the  state  of  the  body,  and 
of  the  circumstances  bearing  upon  it,  and  shall  have  added  any  informa- 
tion that  he  may  be  able  to  collect,  with  the  Christian  names,  surname, 
age,  profession,  and  birthplace,  of  the  deceased.' 

Cod.  Crim.  Proc,  44. — '  If  a  violent  death  occurs,  or  a  death  whose 
cause  is  unknown  or  unexpected,  the  public  prosecutor  shall  obtain  the 
assistance  of  two  medical  officers  of  health,  who  shall  make  a  report  on 
the  causes  of  death  and  the  condition  of  the  body.  The  persons  referred 
to  in  the  present  article  and  the  preceding  article  shall  be  put  upon  their 
oath,  before  the  public  prosecutor,  to  make  their  report  and  to  give  their 
opinion  on  their  honour  and  conscience.' 


SUDDEN  DEATH. 


nite,  suspicions  are  expressed  openly,  and  the  law  is  set  in 
motion  ;  an  inquiry  is  held,  and  in  three  or  four  weeks  after 
the  decease  exhumation  is  ordered,  so  that  a  post-mortem 
examination  may  be  made. 

I  repeat  that  this  is  the  usual  course  of  events  when  death 
has  been  unforeseen  and  sudden,  without  there  being  any 
reason  to  ascribe  it  to  an  injury. 

We  now  enter  upon  the  subject  of  sudden  death  apart 
from  injury. 

Why  does  sudden  death  occur  ?  No  one  dies  suddenly 
apart  from  the  effects  of  violence,  as  long  as  all  the  organs 
are  sound  ;  but  there  are  some  diseases  which  develop  slowly 
and  secretly,  without  the  attention  of  the  patients  having 
been  called  to  them  by  any  pain  or  by  any  feeling  of  ill- 
ness, and  without  a  physician  having  ever  been  called  in,  and 
which  terminate  naturally  by  a  rapid  death.  Among  these 
diseases  I  will  mention  diabetes  and  arteriosclerosis,  accom- 
panied by  atrophy  of  the  kidneys.  The  person  affected  with 
arteriosclerosis  apparently  enjoys  good  health  ;  he  may  some- 
times present  digestive  troubles,  and  fancies  that  he  is  dys- 
peptic ;  he  attributes  any  slight  temporary  indispositions  to 
his  stomach  :  moreover,  the  course  of  the  disease  is  long,  yet 
an  emotion  or  a  chill  may  kill  the  patient.  A  diabetic  patient 
may  also  look  well ;  he  is  cheerful,  he  eats  well  and  sleeps 
well.  The  day  arrives  at  last  when  he  becomes  comatose, 
vomits,  and  dies,  while  those  around  him  speak  of  poisoning. 

These,  Gentlemen,  are  not  sudden  deaths  in  the  strict 
sense  of  the  term.  Literally  speaking,  death  is  always 
sudden  ;  that  is  to  say,  life  ceases  in  an  instant,  if  we  hold 
the  opinion,  as  do  the  sick  man's  relatives  and  friends,  that 
the  moment  of  death  is  determined  by  the  last  breath  or 
the  last  beat  of  the  heart.  But  that  which  has  received  the 
name  of  sudden  death,  both  among  ordinary  people  and  in 
the  law-courts,  is  a  death  which  is  not  preceded  at  all,  or 
only  for  a  short  time,  by  alarming  morbid  phenomena.  The 
word  '  unforeseen'  ought  to  be  added  to  the  word  '  sudden.' 
It  is  this  condition  which,  in  the  eyes  of  everybody,  as  well 
as  of  the  law,  takes  precedence  of  all  other  considerations. 
And  in  order  to  avoid  giving  cause  for  any  future  misunder- 


SUDDEN  DEATH.  123 


standing,  we  will  define  sudden  death  as  'the  rapid  and 
unforeseen  termination  of  an  acute  or  chronic  disease,  which 
has  in  most  cases  developed  in  a  latent  manner.' 

When  the  state  of  apparent  health  has  continued  up  to 
the  last  moment,  the  cause  of  death  may  be  guessed,  not- 
withstanding. Here  is  an  example  of  rapid,  unforeseen 
death  which  is  easily  suspected  :  the  primary  and  secondary 
symptoms  of  apoplexy  are  well  known  to  everyone,  and 
there  is  no  need  to  give  information  to  the  authorities,  or 
for  the  officers  of  the  court  to  intervene  in  such  cases.  Of 
all  sudden  and  unexpected  deaths,  apoplexy  furnishes  the 
fewest  autopsies  and  inquests. 

The  officers  of  the  court  include  in  the  category  of  sudden 
deaths  those  cases  where  individuals  who  appeared  to  be  in 
good  health  at  the  time  have  lived  for  four  or  five  days  after 
the  fatal  seizure. 

Sudden  death  is  seen  towards  the  close  of  certain  pro- 
tracted diseases,  such  as  phthisis  and  cancer.  You  are  all 
acquainted  with  the  occurrence  of  fatal  syncope  in  phthisis, 
and  are  aware  that  embolism  may  happen  in  phthisis  or 
cancer.  In  certain  acute  diseases,  such  as  typhoid  fever, 
sudden  death  is  equally  liable  to  happen,  and  M.  Dieulafoy 
devoted  his  inaugural  thesis  to  the  subject.  But  these  are 
all  accidents  in  familiar  diseases.  In  the  strict  sense  in 
which  we  are  speaking,  sudden  death  is  an  unexpected 
accident  in  a  disease  of  whose  existence  we  were  quite 
ignorant,  and  which  has  run  its  course  without  attracting 
any  attention  at  all. 

Fifty  years  ago  the  doctrine  of  Bichat  prevailed,  according 
to  which  it  was  said  that  death  took  place  by  the  heart,  the 
lungs,  or  the  brain. 

To-day  we  can  assert,  at  any  rate  as  far  as  sudden  death 
is  concerned,  that  death  is  especially  apt  to  be  brought 
about  by  the  kidneys,  and  we  ought  to  restore  the  humoral 
theory  to  a  place  of  honour. 

M.  Lesser,  a  German  medical  jurist,  whose  name  is  of 
great  weight,  takes  too  narrow  a  view  of  the  question  of 
sudden  death.  He  is  faithful  to  the  ideas  of  Galen,  and  is 
convinced  of  the  truth  of  the  old  phrase,  CoruUimum  moriens. 


124  SUDDEN  DEATH. 


Out  of  100  deaths,  he  attributes  66  to  cardiac  lesions,  the 
remainder  to  unknown  causes.  But  we  know  that  in  those 
cardiac  affections  capable  of  inducing  sudden  death  there 
are  very  often  renal  lesions,  and  an  analysis  of  Lesser's  cases 
proves  that  he  himself  met  with  them. 

We  ought.  Gentlemen,  to  classify  the  changes  in  the 
organs  which  may  bring  about  sudden  death.  We  shall 
pass  under  review  successively  the  alterations  in  the  circu- 
latory system,  those  in  the  nervous  system,  those  in  the 
respiratory  system,  those  in  the  digestive  system,  those  in 
the  genito-urinary  system,  specially  the  female  organs,  and 
the  kidneys,  and  also  the  alterations  in  the  humours,  i.e., 
diabetes,  albuminuria,  haemophilia,  etc.  I  am  well  aware 
that  this  classification  is  not  free  from  the  charge  of  being 
forced  and  artificial ;  but  no  natural  classification  can  be 
constructed,  and  I  shall  try  to  leave  nothing  to  be  desired  in 
the  way  of  precision  and  clearness. 

I  shall  then  speak  of  sudden  death  in  new-born  infants 
and  in  children  under  two  years  of  age.  Sudden  death  is  as 
common  in  the  earliest  years  as  in  old  age,  and  it  often  gives 
rise  to  medico-legal  blunders,  against  which  I  shall  have  to 
put  you  on  your  guard. 

Besides  organic  lesions  and  alteration  of  the  humours,  it 
is  necessary  to  allude  to  circumstances  which  may  be  called 
'  occasional  causes,'  and  it  is  of  importance  to  be  acquainted 
with  them.  They  include  acts  of  violence,  anger,  conflicts, 
strong  emotions,  and  sometimes  special  unfortunate  suscep- 
tibilities of  the  individual.  The  effects  of  cold  and  heat  will 
likewise  engage  our  attention,  for  popular  opinion  ascribes 
most  cases  of  sudden  death  to  some  exceptional  external 
circumstance  or  other. 

Gentlemen,  however  carefully  we  may  perform  every 
autopsy,  however  minute  our  exploration  of  the  body  may  be, 
however  thorough  may  be  our  knowledge  of  the  causes  of 
sudden  death,  we  sometimes  meet  with  cases  which  it  is 
impossible  to  explain.  The  proportion  is  about  8  or  lo  per 
cent.  Often  the  body  submitted  to  us  for  examination  is  in 
a  more  or  less  advanced  state  of  putrefaction  ;  with  the  best 
will  in  the  world,  our  inquiry  must  remain  incomplete,  and 


SUDDEN  DEATH.  125 


present  lacuncB  due  to  the  impossibility  of  prosecuting  our 
researches  further,  and  particularly  to  our  inability  to  ex- 
amine with  the  microscope  tissues  that  are  undergoing 
decomposition.  Sometimes,  even  although  we  cannot  plead 
the  existence  of  putrefactive  changes,  we  cannot  ascertain 
the  real  cause  of  death. 

I  will  enumerate  some  of  the  circumstances  which  render 
us  thus  impotent.  Remember,  then,  that  there  is  a  certain 
number  of  cases  wherein  it  is  impossible  to  assert  that 
sudden  death  is  the  consequence  of  any  specified  lesion. 
That  is  an  important  fact.  Moreover,  the  officers  of  the 
court  do  not  ask  you  what  the  disease  was  which  caused  the 
sudden  death  of  the  deceased  ;  they  require  you  to  give 
evidence  as  to  whether  or  not  death  was  due  to  violence  or 
to  the  effects  of  poisoning.  If  you  find  no  marks  of  violence 
and  no  traces  of  poison  in  the  body,  say  so  simply.  Justice 
will  be  satisfied,  for  it  is  all  that  it  desires  to  know. 


LECTURE  II. 

SUDDEN  DEATH  DUE  TO  LESIONS  OF  THE  CIRCULATORY 

SYSTEM. 

Gentlemen, — Sudden  death  often  occurs  as  a  result  of 
changes  which  take  place  in  the  circulatory  system,  but  it  is 
not  essential  that  there  should  be  any  lesion  of  importance. 
A  lesion  may  remain  latent  during  the  greater  part  of  life,  and 
be  only  revealed  by  accident.  This  fact  is  a  predominant 
feature  all  through  the  history  of  sudden  death.  A  lesion  of 
this  kind  may  have  its  seat  in  the  heart  or  the  vessels 
(arteries,  veins,  or  capillaries),  but  especially  in  the  vessels 
of  the  brain  or  kidneys. 

I.  LESIONS  OF  THE  HEART. 

A.  Cardiac  Muscle. — In  the  circulatory  apparatus  the 
principal  organ  is  the  muscle  of  the  heart.  The  action  of 
the  cardiac  muscle  may  cease  although  there  is  no  valvular 
lesion  ;  this  may  happen  in  the  course  of  certain  diseases  in 
which  it  is  impossible  to  make  a  diagnosis  during  life.  What 
are  those  diseases  ? 

I.  Fatty  Overgrowth  of  the  Heart. — A  certain  amount  of  fat 
is  normally  deposited  on  the  surface  of  the  heart.  This 
deposit  begins  as  early  as  the  third  week  and  increases  as 
age  advances.  You  have  all  noticed,  when  examining  hearts 
in  the  post-mortem  theatre,  those  yellowish  streaks  along  the 
course  of  the  vessels,  and  those  spots  of  yellow  fat  sprinkled 
over  the  surface  of  the  muscle,  which  indicate  this  condition. 

If  the  fatty  overgrowth  is  considerable,  the  muscular  fibres 


LESIONS  OF  THE  CIRCULATORY  SYSTEM.  127 

can  no  longer  be  seen  ;  the  heart  seems  entirely  enveloped 
in  a  yellow  covering  of  fat. 

When  the  overgrowth  is  less  pronounced,  the  heart  pre- 
sents on  its  surface  yellow  discs,  slightly  raised,  which  may 
be  likened  to  the  lenses  of  spectacles  or  of  an  opera-glass, 
and  which  conceal,  in  the  form  of  islets,  portions  of  the 
muscle  lying  beneath.  Muscular  tissue  may  sometimes  be 
found  underneath  these  fatty  patches,  but  the  fat  may  also 
infiltrate  the  muscular  tissue  itself,  forming  gaps  in  it  where 
the  presence  of  muscular  fibres  can  only  be  detected  by  the 
aid  of  the  microscope. 

The  living  person  who  has  fatty  overgrowth  of  the  heart 
does  not  believe  himself  to  be  ill.  He  looks  well :  he  is 
perhaps  a  little  short  of  breath,  but  he  has  never  had  an 
attack  of  severe  dyspnoea  or  any  symptoms  of  angina  pectoris, 
which  would  have  given  warning  of  his  condition  ;  ausculta- 
tion, if  practised,  reveals  nothing.  The  physician  will  ascer- 
tain that  the  heart  is  somewhat  enlarged,  that  the  valvular 
sounds  are  a  trifle  weak,  and  that  the  impulse  of  the  heart  is 
somewhat  feebler  than  normal,  but  he  will  not  be  able  to 
make  a  precise  diagnosis ;  and  yet  that  individual  is  suffer- 
ing from  an  affection  of  the  heart  which  renders  him  liable 
to  sudden  death. 

This  fatty  overgrowth  does  not  always  make  its  first 
appearance  in  the  second  period  of  life,  i.e.  after  the  40th 
year  :   it  sometimes  exists  in  children  15  or  16  years  of  age. 

I  remember  two  accidents  which  happened  under  the 
same  circumstances  at  the  Sainte-Barbe  institution  while  I 
was  physician  there.  Two  children  died  suddenly  in  a  cold 
bath.  In  one  case  the  relatives  asked  for  a  post-mortem 
examination ;  in  the  other  they  wished  to  have  the  bod}- 
embalmed  :  in  both  these  children  the  heart  was  so  loaded 
with  fat  that  it  was  impossible  to  see  the  muscular  fibre. 
What  was  the  matter  with  these  children  ?  You  have 
doubtless  heard  the  word  'infantilism'  pronounced.  It 
denotes  a  condition  which  has  not  received  all  the  considera- 
tion it  deserves.  The  children  of  large  cities,  such  as  Paris, 
Lyons,  Marseilles,  Lille,  etc.,  exist  under  certain  peculiar 
conditions.     Take    the    little    Parisian   for    example  :    he    is 


128  SUDDEN  DEATH. 


confined  to  very  narrow  surroundings  ;  his  intellect  de- 
velopes  rapidly,  and  is  precocious.  That  child  will  become 
towards  his  tenth  or  eleventh  year  the  street-Arab  (gavroche) 
of  Victor  Hugo,  if  he  belongs  to  the  lower  classes,  or  a 
"  little  prodigy  "  if  he  is  born  in  the  middle  class.  At  this 
age  his  energies  seem  to  be  arrested;  he  can  no  longer 
maintain  the  position  he  held  in  his  class  ;  the  children  from 
the  provinces,  whom  he  left  far  behind  at  the  commence- 
ment of  his  studies,  now  pass  him  by.  At  the  same  time 
the  development  of  his  testicles  is  arrested,  and  he  grows 
fat ;  the  breasts  enlarge,  and  sometimes  an  abscess  forms  in 
them.  I  have  had  to  open  sixty  or  seventy  while  I  was 
physician  to  Sainte-Barbe.  The  children  grow  no  taller, 
and  sometimes  they  are  like  bags  of  fat.  These  children, 
Gentlemen,  ought  not  to  undergo  the  douche  or  to  enter  a 
cold  bath.  A  violent  shock  to  the  circulation  is  sufficient 
to  stop  the  movements  of  their  hearts,  and  thus  bring  about 
sudden  death. 

2.  Fatty  Degeneration  of  the  Muscular  Tissue  of  the  Heart. — 
Here  we  no  longer  find  yellow  patches  scattered  over  the 
surface  of  the  heart ;  the  alteration  is  more  profound ;  the 
muscle  itself  is  changed,  and  is  converted  into  fat.  This 
transformation  of  the  muscular  fibres  takes  place  in  patches. 
If  you  make  a  section  of  a  heart  that  has  undergone  this 
modification,  and  wash  it,  you  will  see  that  its  substance  is 
studded  with  islets  of  a  special  colour — a  brownish  or  buff 
red — reminding  you,  as  Laennec  described  it,  of  the  tint 
of  dead  leaves,  and  its  nature  is  revealed  by  microscopical 
examination.  A  German  author,  comparing  it  to  the  colour 
of  a  horse's  coat,  has  appropriately  called  it  "  dappled." 
Fatty  degeneration  developes  slowly  and  secretly ;  it  often 
attacks  hearts  that  are  hypertrophied,  and  it  gives  rise  to 
the  same  dangers  as  fatty  overgrowth. 

3.  Fibroid  Degeneration  of  the  Heart. — Fibroid  degeneration 
of  the  heart,  which  likewise  developes  in  patches,  is  due 
to  chronic  myocarditis.  It  has  been  well  described  by 
M.  Letulle.  The  patches  may  invade  both  the  muscular 
tissue  of  the  wall  and  that  of  the  musculi  papillares ;  it  is 
this  condition  which   leads  to  rupture  of  the  heart.     The 


LESIONS  OF  THE  CIRCULATORY  SYSTEM.  129 


tendons  thus  degenerated  may  snap  as  a  result  of  a  fit  of 
anger  or  other  violent  emotion,  or  of  coitus,  and  their 
rupture  entails  sudden  death,  the  exact  cause  of  which 
cannot  be  determined  without  2,  post-mortem  examination. 

Acute  myocarditis  accompanies  infective  diseases,  such 
as  typhoid  fever,  small-pox,  pneumonia,  etc. 

4.  Lesions  of  the  Coronary  Arteries. — These  arteries  are 
sometimes  affected  by  arterio-sclerosis ;  they  become 
thickened  and  nodulated,  their  calibre  is  diminished,  and 
the  blood-supply  to  the  heart  is  lessened,  often  to  a  remark- 
able degree.  Degeneration  of  the  cardiac  muscle  is  the 
consequence  of  all  this,  and  leads  to  sudden  death. 

5.  Rupture  of  the  JT^ar;^.^  Rupture  of  the  heart  was  formerly 
known  as  '  aneurysm  of  the  heart.'  Aneurysm  of  the  heart, 
analogous  to  that  of  the  arteries,  has  no  existence. 

These  lacerations  of  the  wall  of  the  heart  are  rare,  it  is 
true,  but  they  happen  occasionally.  Thirty  years  ago  Aran 
collected  33  cases,  of  which  25  were  ruptures  of  the  left 
ventricle,  3  of  the  right  auricle,  i  of  both  ventricles,  and  i  of 
the  right  auricle  and  right  ventricle. 

These  ruptures  are  not  instantaneous  ;  on  the  contrary, 
there  is  a  preliminary  alteration  by  fibroid  degeneration. 
The  tearing  proceeds  from  within  outwards,  widening  in  its 
progress,  and  becoming  so  extensive  that  the  aperture  on 
the  outer  surface  of  the  heart  is  much  larger  than  that  on 
the  inner  surface.  While  this  process  is  going  on,  the  con- 
traction of  the  heart  drives  a  few  drops  of  blood  into  the 
rent ;  the  blood  thus  forced  by  each  impulse  into  the  rent 
travels  farther  forwards,  at  the  same  time  making  it  broader. 
Those  authors  were  mistaken  who  believed  that  ruptures  of 
the  heart  could  be  effected  from  without  inwards.* 

In  cases  where  the  heart  is  incompletely  torn  through, 
the  laceration  always  starts  from  the  internal  surface  of  the 
heart. 

Ruptures  of  the  apex  of  the  heart  are  tolerably  frequent. 
It  was  from  a  rupture  of  this  kind  that  Talma  died. 

*  Wilks  and  Moxon,  '  Lectures  on  Pathological  Anatomy,'  2nd  edition, 
p.  116,  mention  a  specimen  in  which  there  were  two  or  three  merely- 
superficial  rents  in  the  heart  from  structural  disease.  Death  took  place 
from  haemorrhage  into  the  pericardium  — Tr.^xslator. 

9 


SUDDEN  DEATH. 


The  heart  may  give  way  in  the  course  of  certain  infective 
diseases,  such  as  typhoid  fever,  small-pox,  infective  pneu- 
monia, etc.  The  rupture  is  then  due  to  an  acute  myo- 
carditis, which  lessens  the  resistance  of  the  muscle.  When 
a  physician  finds  the  heart  becoming  weak  in  a  patient 
suffering  from  one  of  these  diseases,  he  should  anticipate  the 
possibility  of  an  accident  of  this  kind. 

In  rupture  of  the  heart,  death  seems  to  depend  upon  the 
insufficient  quantity  of  the  blood  propelled  by  the  heart  into 
the  general  circulation,  and  also  upon  the  resistance  offered 
to  the  movements  of  the  heart  by  the  pressure  of  the  clot 
poured  out  into  the  pericardium.  This  clot  may  weigh 
7  to  14  oz. 

B.  Pericardium. — We  will  now  consider  lesions  of  the 
pericardium.  The  symptoms  of  acute  pericarditis  are  so  well 
known  that  I  will  not  dilate  upon  them.  But  it  is  necessary 
to  remind  you  of  those  numerous  forms  of  pericarditis 
which  may  exist  alone,  or  may  precede  by  some  days  the 
other  manifestations  of  rheumatism,  or  which  sometimes 
appear  suddenly  in  alcoholic  subjects,  for  example,  as  well 
as  hsemorrhagic  pericarditis,  to  which  Dr.  de  Lacrouzille 
devoted  his  thesis.  Abundance  of  effusion  into  the  peri- 
cardium constitutes  a  grave  danger. 

For  the  last  forty  years  paracentesis  pericardii  has  been 
performed  when  the  fluid  is  effused  in  large  quantity.  Some- 
times during  the  process  of  tapping  the  heart  suddenly  stops, 
and  fatal  syncope  results.  The  responsibility  of  the  physician 
may  be  called  in  question  under  such  circumstances  ;  there- 
fore I  would  advise  you  never  to  undertake  paracentesis  of 
the  pericardium  without  the  help  of  a  colleague,  and  without 
having  forewarned  the  patient's  relatives  of  the  possibility  of 
a  fatal  termination. 

As  a  consequence  of  pericarditis,  false  membranes  may 
have  formed,  which  may  cover  both  folds  of  the  pericardium, 
or  may  form  adhesions  between  them,  and  then  one  of  two 
conditions  is  met  with  :  either  the  adhesions  are  loose  and 
long  enough  to  allow  of  the  normal  free  play  of  the  heart, 
and  of  the  movements  of  the  two  pericardial  surfaces  on 
each  other,  or  they  are  so  short  as  to  approximate,  or  even 


LESIONS  OF  THE  CIRCULATORY  SYSTEM.  131 

to  closely  unite,  the  two  surfaces,  and  so  produce  adherent 
pericardium.  The  diagnosis  of  adherent  pericardium  is 
difficult  in  the  living  subject ;  it  is  not  an  uncommon  thing 
for  it  to  be  found  absent  post-mortem,  though  its  existence 
had  been  suspected  during  life  ;  or,  on  the  other  hand,  for  it 
to  be  found  present  when  nothing  had  pointed  to  its  presence 
during  life.  It  is  a  very  grave  condition,  notwithstanding, 
for  in  the  notes  of  cases  of  sudden  death  due  to  alterations 
in  the  heart  that  I  have  collected  at  the  Morgue,  sudden 
death  has  in  several  instances  been  due  to  adherent  peri- 
cardium. The  heart  is  somewhat  enlarged ;  the  muscle 
presents  patches  of  fibroid  tissue  wherever  the  adhesions  are 
attached,  exemplifying  the  fibroid  myocarditis  of  M.  Letulle. 
The  individual  whose  heart  has  undergone  this  change  may 
live,  and  may  even  feel  no  appreciable  inconvenience,  but 
after  it  has  lasted  some  time  he  may  die  suddenly  under  the 
influence  of  some  emotion  or  violent  outburst  of  anger  ;  his 
heart,  contracting  imperfectly,  can  no  longer  perform  what 
is  required  of  it. 

The  most  typical  example  that  I  can  cite  to  you  is 
the  following :  A  peasant  was  riding  along  a  road  in  his 
cart,  when  he  saw  three  women  gathering  corn-flowers  in  a 
field  that  belonged  to  him.  He  wanted  to  stop  them,  and 
cracked  his  whip  in  order  to  scare  them  away ;  then,  seeing 
that  the  women  kept  moving  about  in  the  field,  he  descended 
from  the  cart  and  ran  towards  them.  The  women  hurried 
away,  and  in  doing  so  one  of  them  fell  to  the  ground.  The 
peasant  went  to  her  and  picked  her  up.  Her  two  com- 
panions, furious  at  having  been  interfered  with  and  chased, 
maintained  that  he  had  unmercifully  beaten  the  woman  who 
had  fallen  down,  which  the  peasant  indignantly  denied. 
The  passers-by  collected  together,  and  conducted  the  two 
women,  together  with  the  peasant  and  his  alleged  victim,  to 
the  police-station.  The  woman  died,  succumbing  to  a 
paroxysm  of  dyspnoea.  A  post-mortem  examination  was 
ordered  to  be  made,  and  on  the  body  only  insignificant 
injuries  were  found;  but  she  had  adherent  pericardium, 
which  had  been  unknown  to  everybody. 

This    is    not    a    solitary    instance.    Gentlemen,    but   it    is 


132  SUDDEN  DEATH. 


typical,  because  the  condition  of  which  we  are  now  speaking 
was  the  only  lesion  that  could  account  for  death.  Such  a 
termination  is  usual,  but  it  would  be  going  too  far  to  say 
that  it  is  invariable.  M.  Lesser  thinks  that  sudden  death 
can  only  happen  when  other  morbid  conditions  co-exist. 

C.  Aortic  Incompetence. — I  come  now  to  valvular  lesions. 
Aortic  incompetence,  which  is  one  of  the  consequences  of 
articular  rheumatism  contracted  in  youth,  is  rightly  con- 
sidered by  many  authors  as  a  predisposing  cause  of  sudden 
death.  A  person  with  undoubted  aortic  incompetence  may 
live,  it  is  true,  for  many  years.  It  is  recognized  by  the 
pallor  of  the  face,  the  cardiac  murmur,  the  visible  pulse  so 
well  described  by  Corrigan,  and  which  has  been  called  after 
him  '  Corrigan's  pulse ':  the  carotid  arteries  throb  in  a  very 
violent  manner.  How  is  the  mechanism  of  sudden  death 
from  this  cause  to  be  explained  ?  M.  Mauriac  has  observed 
in  his  inaugural  thesis  that  in  aortic  incompetence  the 
blood  propelled  by  each  contraction  of  the  ventricle  into  the 
aorta  does  not  remain  there ;  a  certain  amount  flows  back 
into  the  heart  ;  the  coronary  arteries  no  longer  receive  a 
sufficient  supply  of  blood  ;  their  orifices  are  closed  by  the 
sigmoid  valves  during  the  ventricular  systole,  and  in  diastole 
their  orifices  become  patent  ;  but,  as  a  part  of  the  blood 
driven  forwards  falls  back  into  the  heart,  the  tension  at  the 
mouths  of  the  arteries  is  much  lower  than  it  should  be. 
When  the  sigmoid  valves  are  sound,  they  entirely  prevent 
the  reflux  of  the  blood-stream.  In  aortic  incompetence  this 
barrier  is  wanting,  and  there  ensues  an  emptiness  of  the 
coronary  arteries  which  ma}^  lead  to  arrest  of  the  heart's 
action. 

This  theory  of  M.  Mauriac  is  partially  true;  but  when 
there  is  aortic  incompetence,  the  left  ventricle  becomes 
hypertrophied,  sometimes  so  much  so  as  to  earn  the  name  of 
cor  hovinum.  For  a  time  the  cardiac  muscle  struggles  suc- 
cessfull}^  with  the  obstacle  which  impedes  its  functions,  but 
soon,  as  in  all  muscular  hypertrophies — hypertrophy  of  the 
bladder  in  cases  of  stricture  of  the  urethra,  for  example — its 
fibres  undergo  fatty  or  fibroid  degeneration  ;  they  are  larger 
than  normal,  but  less  powerful.     The  anaemia  of  the  heart 


LESIONS  OF  THE  CIRCULATORY  SYSTEM.  133 

diminishes  the  vitahty  of  its  fibres,  it  is  true,  but  there  is 
also  degeneration  of  those  fibres.  When  the  volume  of 
blood  propelled  into  the  aorta  falls  back  in  part  into  the 
ventricle,  Corrigan's  pulse  may  be  felt.  It  is  sometimes 
very  forcible,  and  proves  that  the  blood  is  driven  into 
arteries  which  are  almost  empty.  When  the  blood  flows 
thus  intermittently,  some  parts  of  the  body  are  of  necessity 
insufficiently  supplied  :  the  face  is  pale,  because  part  of  its 
share  of  blood  does  not  reach  it — it  falls  back  into  the  heart, 
instead  of  being  projected  along  the  aorta;  we  find,  there- 
fore, a  general  anaemia,  particularly  an  anaemia  of  the  brain. 
Sudden  death  in  aortic  incompetence  is  therefore  a  product 
of  three  factors — anaemia  of  the  heart,  degeneration  of  the 
heart,  and  anaemia  of  the  brain  ;  and  if  an  individual  suffering 
from  aortic  incompetence  is  obliged  to  make  a  great  effort 
or  undergoes  a  severe  shock,  he  may  die  from  cardiac 
syncope  or  from  cerebral  syncope. 

D.  Mitral  and  Tricuspid  Incompetence. — In  mitral  in- 
competence, as  a  rule,  sudden  death  is  less  to  be  feared  ;  it 
necessitates  an  inquest  less  frequently.  The  patients  suffer 
from  dyspnoea  and  cedema  of  the  lower  limbs,  and  they 
present  all  the  well-known  symptoms  of  cardiac  affections  ; 
they  are  known  to  have  heart  disease.  A  medico-legal 
inquiry  may  be  ordered,  however,  under  two  particular  con- 
ditions :  either  when  the  mitral  incompetence  is  in  a  very 
early  stage,  or  else  when  it  is  very  advanced. 

In  the  first  case,  the  symptoms  are  but  slightly  pro- 
nounced ;  the  patient  is  not  aware  that  he  has  anything 
wrong  with  his  heart.  If  he  does  know  it,  he  may  not  have 
suffered  from  dyspnoea,  and  he  has  probably  had  no  dropsy ; 
nevertheless,  the  cardiac  muscle  may  already  have  under- 
gone very  decided  alteration.  An  attack  of  pulmonary 
congestion  is  quite  enough,  even  in  a  young  man,  to  bring 
about  sudden  death. 

A  medical  student,  unaware  that  he  was  affected  with 
mitral  incompetence,  went  to  a  public  ball  one  evening ; 
he  danced,  but  had  to  stop  all  of  a  sudden,  as  a  violent 
paroxysm  of  dyspnoea  seized  him.  He  became  cyanosed, 
and  died  shortly  after.     The  autopsy  revealed  the  presence 


134  SUDDEN  DEATH. 


of  mitral  incompetence  ;  the  lungs  were  extremely  congested 
and  gorged  with  blood,  so  that  they  looked  like  two  bags  of 
blood,  and  were  almost  firm  enough  to  stand  upright.  It 
was  ascertained  also  that  this  young  man  had  partaken  of  a 
hearty  meal  before  going  to  the  ball,  and  no  doubt  had 
washed  it  down  with  copious  libations.  That  is  one  of  the 
circumstances  most  favourable  to  produce  congestion.  I 
cannot  too  strongly  urge  upon  you  to  prohibit  those  of  your 
patients  in  whom  you  have  discovered  the  existence  of 
mitral  incompetence  from  dancing,  running  and  taking 
violent  exercise,  especially  after  a  bountiful  repast. 

In  England  diseases  of  the  heart  ending  in  sudden  death 
are  very  frequent.  English  authors  attribute  a  great  many 
sudden  deaths  to  mitral  incompetence ;  they  mention  the 
railway-station  as  one  of  the  commonest  places  where  these 
sudden  deaths  occur.  You  know  how  many  Englishmen 
live  out  of  town  ;  they  are  sometimes  pressed  for  time, 
always  keeping  in  mind  the  hour  of  the  train,  and  have  to 
run  to  catch  it,  and  they  sometimes  die  at  the  very  moment 
of  entering  the  carriage. 

In  the  second  case,  which  corresponds  with  an  advanced 
period  of  mitral  incompetence,  the  symptoms  are  very 
evident ;  there  is  a  feeble  pulse,  oedema  of  the  lower  extre- 
mities, and  anasarca.  You  know  the  classical  picture  of 
these  affections.  In  contrast  with  these  patients  are  others 
who  have  had  no  oedema  and  no  dyspnoea,  or,  at  any  rate, 
only  in  a  slight  degree,  and  yet  their  condition  may  rapidly 
change — on  the  supervention  of  bronchitis,  for  example — 
from  one  that  is  attended  by  but  little  danger  to  one  that  is 
extremely  critical. 

When  there  is  mitral  incompetence,  there  is  usually  some 
pulmonary  congestion  ;  and  when,  in  addition,  there  is  mitral 
obstruction,  the  pulmonary  circulation  is  carried  on  very 
imperfectly.  Some  of  the  blood  which  should  reach  the 
heart  remains  in  the  pulmonary  tissue  ;  the  capacity  of  the 
lungs  for  air  is  diminished,  stasis  of  blood  becomes  persis- 
tent throughout,  and  consequently  the  tissues  become  con- 
densed ;  when  bronchitis  supervenes,  attacks  threatening 
suffocation  develop  at  once,  and  are  very  severe. 


LESIONS  OF  THE  CIRCULATORY  SYSTEM.  135 

This  condition  is  aggravated  when  there  co-exists  a  de- 
formity of  the  spine.  In  lateral  curvature  the  heart  nearly 
always  suffers ;  and  nearly  all  those  who  are  afflicted  with 
angular  curvature  succumb  to  a  superadded  attack  of  bron- 
chitis, which  complicates  the  pre-existing  cardiac  affection. 
The  same  thing  occurs  when  renal  mischief  exists  along 
with  mitral  incompetence.  In  cardiac  affections  this  asso- 
ciation is  by  no  means  uncommon ;  you  know  how  often 
the  kidneys  may  be  impaired.  There  may  not  be  much 
albuminuria,  and  yet  oedema  of  the  lungs  sets  in  very  speedily. 
AlsO;  when  an  individual  who  has  mitral  incompetence  is 
attacked  by  bronchitis,  complicated  with  oedema  of  the 
lungs,  he  sometimes  dies  of  asphyxia  in  the  course  of  a  few 
hours. 

What  has  the  law  to  do  with  cases  of  sudden  death  due 
to  mitral  incompetence  ?  I  have  the  notes  of  a  dozen  cases 
which  furnish  an  answer  to  the  question. 

For  the  last  ten  years,  partly  in  consequence  of  the 
recommendations  of  M.  Huchard,  it  has  been  customary  to 
inject  morphine  to  calm  the  attacks  of  dyspnoea  of  certain 
cardiac  patients.  It  is  not  always  the  family  physician  who 
is  attending  the  patient  who  employs  the  remedy. 

The  attacks  often  come  on  during  the  night,  and  the 
nearest  medical  man,  or  the  one  who  is  on  public  duty  for 
the  night  and  is  prepared  to  come,  is  called  in.  This  physi- 
cian knows  nothing  of  the  patient's  history,  and  he  has  no 
time  to  make  inquiry  ;  he  is  under  the  most  unfavourable 
conditions  for  auscultating  the  patient  whose  circulation 
and  respiration  are  so  embarrassed.  He  gives  an  injection 
of  morphine  to  subdue  the  dyspnoea ;  the  patient  is  some- 
what relieved,  and  his  friends  think  that  he  is  going  to  sleep; 
■he  does  not  sleep,  however ;  therefore  in  half  an  hour  the 
physician  repeats  the  injection,  and  takes  his  leave.  This 
time  the  sick  man  does  go  to  sleep.  Next  morning  a  mes- 
sage is  sent  to  the  physician's  house  to  let  him  know  that 
he  need  not  trouble  to  call,  as  the  patient  died  in  the  night. 

The  question  that  arises  here  in  the  forensic  aspect  is 
this  :  Is  the  physician  culpable  ?  In  nearly  all  cases  which 
I    have  had  to  examine  there  was  albuminuria.      Urasmic 


136  SUDDEN  DEATH. 


coma  is  mistaken  for  sleep  due  to  morphine  ;  it  is  impos- 
sible to  blame  the  injection  of  morphine,  and  say  it  is  that 
which  has  killed  the  patient.  All  that  it  is  possible  to  say 
is  that  the  patient  had  bronchitis  or  cardiac  disturbance 
from  uraemia,  and  that  the  morphine  injection  would  not 
hasten  the  final  coma  by  half  an  hour,  even  if  it  had  such 
an  effect  at  all. 

It  is  not  only  morphine  that  has  been  blamed  for  such 
accidents  ;  these  have  also  been  ascribed  to  wet-cupping, 
emetics,  inhalations  of  ether,  and  to  every  other  mode  of 
treatment. 

You  see,  then.  Gentlemen,  that  you  must  exercise  caution. 
When  you  are  summoned  to  a  patient  under  such  condi- 
tions, before  taking  any  steps  to  give  relief,  warn  the  rela- 
tives of  all  the  accidents  which  may  follow  your  treatment 
— not  because  of  it,  but  in  spite  of  it. 

In  tricuspid  incompetence  the  same  phenomena  are  observed. 
When  there  is  emphysema  at  the  same  time,  attacks  of 
bronchitis  are  frequent  and  severe ;  when  there  is  what 
Trousseau  called  an  '  overstrained  heart  '  [ccenr  force),  it 
denotes  dilatation  of  the  right  ventricle,  and  the  pulmonary 
circulation  is  obstructed  as  much  as  in  the  preceding  case. 

E.  Endocarditis, — Endocarditis  gives  rise  to  medico-legal 
inquiries  of  a  special  kind.  I  do  not  refer  to  the  endocar- 
ditis with  hyperpyrexia,  which  comes  on  unexpectedly  in 
the  course  of  acute  rheumatism,  and  sends  the  temperature 
up  to  104°  or  106°  F.,  and  which  has  a  rapidly  fatal  termi- 
nation ;  such  a  case  is  not  followed  by  an  inquest.  But 
there  is  infective  endocarditis,  which  has  been  well  described 
by  M.  Haust,  who  recognizes  two  forms  of  it.  In  the  first 
the  infection  is  limited  to  the  heart  ;  in  the  second  it  starts 
in  the  heart,  and  thence  becomes  general. 

Let  me  give  you  an  example  of  infective  ulcerative  endo- 
carditis, limited  exclusively  to  the  heart  :  A  young  mason, 
sixteen  years  of  age,  came  down  the  ladder,  at  the  top  of 
which  he  had  been  working  one  da5^  because  he  felt  unwell 
and  out  of  sorts.  He  met  his  father  in  the  street,  who 
reproached  him  with  being  lazy,  and  ended  by  boxing  his 
ears.     The  boy  fell  down,  but  was  picked  up,  and  was  found 


LESIONS  OF  THE  CIRCULATORY  SYSTEM.  137 

to  be  hemiplegic  and  aphasic.  He  was  taken  to  the  hospital 
and  put  under  the  care  of  Dr.  Lorain,  whose  house-physician 
I  was  at  the  time.  Dr.  Lorain  detected  a  cardiac  murmur, 
indicating  mitral  incompetence  ;  the  intensity  of  the  murmur 
varied  from  day  to  day,  and  in  a  month  was  no  longer  to  be 
heard  ;  the  patient  improved,  but  he  did  not  altogether 
regain  the  power  of  speech. 

Now,  that  lad  had  a  wound  on  his  foot  which  he  had 
neglected,  and  which  originated  the  infective  endocarditis 
limited  to  the  endocardium,  and  a  deposit  of  fibrin  had 
formed  on  the  valves. 

Under  the  influence  of  the  emotion  caused  by  the  blow- 
ing-up his  father  had  given  him,  an  embolus  was  detached, 
which  was  carried  along  in  the  blood-stream  till  it  blocked 
the  middle  cerebral  artery  and  produced  hemiplegia. 

When  the  infective  phenomena  are  general,  and  there  is 
multiple  embolism,  we  have  to  do  with  M.  Haust^s  second 
form. 

How  are  we  brought  in  contact  with  endocarditis  in 
medical  jurisprudence  ?  A  little  child  had  received  a  blow 
on  his  scalp  from  the  ruler  of  an  under-master  at  school. 
Neither  he  nor  his  parents  paid  any  attention  to  it  at  the 
time;  but  the  child  fell  ill,  became  delirious,  and  the  doctor 
pronounced  it  to  be  a  case  of  meningitis,  brought  on  by  the 
blow  inflicted  by  the  under-master. 

The  child  died,  and  the  body  was  transferred  to  the 
Morgue.  The  autopsy  revealed  the  existence  of  infective 
ulcerative  endocarditis.  Gentlemen^  the  violence  of  the 
blow  had  been  grossly  exaggerated.  It  was  clearly  ver\- 
wrong  of  the  under-master  to  strike  the  child ;  but  there 
was  a  marked  disproportion  between  the  slightness  of  the 
blow  and  the  supposed  consequences. 

Infective  ulcerative  endocarditis  is  frequent  as  a  result  of 
slight  wounds,  such  as  a  graze  of  the  calf,  foot  or  heel.  It 
does  not  seem  to  follow  lesions  of  the  alimentary  canal  or 
of  the  bronchi,  nor  does  it  appear  as  a  result  of  surgical 
operations  or  amputations  ;  it  seems  rather  to  proceed  from 
superficial  sores  that  are  attended  to  imperfectly  or  not 
at  ah. 


138  SUDDEN  DEATH. 

Endocarditis  often  leads  to  aneurysm  of  the  valves.  In 
consequence  of  the  ulceration  to  which  inflammation  of  the 
endocardium  gives  rise,  lacerations  are  produced.  Small 
excavated  foci,  caused  by  ulceration,  form  in  the  neighbour- 
hood of  or  upon  the  sigmoid  valves  :  this  may  bring  about 
sudden  death  by  embolism.  But,  as  a  general  rule,  when 
there  is  ulceration  on  one  surface  only,  fibrin  is  deposited 
on  it  and  remains  there.  When  ulceration  goes  on  to  per- 
foration of  the  septum,  numerous  emboli  form,  and  are 
carried  to  all  parts  of  the  system. 

One  last  word  as  to  endocarditis,  namely,  on  the  treat- 
ment by  salicylic  acid  and  salicylate  of  soda.  The  number 
of  persons  treated  for  endocarditis  in  rheumatic  fever  by 
salicylate  of  soda,  and  who  have  benefited  by  this  treat- 
ment, is  enormous.  It  is  only  when  the  kidneys  are  diseased, 
and  do  not  perform  their  functions  duly,  that  the  salicy- 
late, which  has  a  cumulative  action,  becomes  a  dangerous 
remedy. 

F.  Angina  Pectoris, — Angina  pectoris  comes  well  within 
our  scope,  for  an  Englishman,  Dr.  Forbes,  states  that  out 
of  sixty-four  persons  thus  affected  that  he  has  met  with, 
forty-nine  died  suddenly  ;  still,  a  certain  number  of  persons 
affected  with  this  disease  live  thirty  or  forty  years,  and  die 
of  something  quite  different. 

We,  as  medical  jurists,  may  have  to  interfere,  because 
people  may  die  in  what  seems  to  be  a  first  attack ;  I  say 
'  seems,'  for  we  are  never  certain  that  the  mishap  which  has 
been  witnessed  by  no  medical  man,  and  which  has  carried 
off  the  patient,  was  an  attack  of  angina  pectoris ;  and  it  is 
this  uncertainty  which  looks  suspicious  to  the  eyes  of  the 
law.  Moreover,  a  person  may  die  not  only  during  an 
attack  of  angina  pectoris,  but  also  in  the  interval  between 
the  attacks. 

What  is  the  danger  which  threatens  a  person  in  angina 
pectoris  ? 

You  know  that  angina  pectoris  is  present  when  the  great 
vessels  are  diseased,  and  when  the  coronary  arteries  are 
degenerated,  thickened  and  tortuous.  The  muscular  fibre 
of  the  heart,  which  receives  less  blood,  and  is  badly  nourished, 


LESIONS  OF  THE  CIRCULATORY  SYSTEM.  139 

undergoes  fibroid  degeneration ;  the  altered  muscle  stops 
either  in  or  apart  from  an  attack,  and  the  patient  dies  of 
syncope. 

If  the  medico-legal  expert  does  not  find  any  lesion  of  the 
coronary  arteries,  or,  at  most,  a  slight  thickening,  should 
he  say  that  death  is  due  to  angina  pectoris  ?  I  think  not, 
for  we  find  similar  lesions  without  there  having  been  any 
angina.  The  presence  of  more  or  less  extensive  fibroid 
patches  will  suggest  the  idea  of  myocarditis.  In  most 
cases  it  is  very  hard  to  decide.  Changes  in  the  ganglia  and 
inflammation  of  the  pneumogastric  and  phrenic  nerves 
have  been  spoken  of  as  causes  of  angina  pectoris  ;  it  has 
been  said  that  it  is  possible  to  recognize  induration  and 
redness  of  these  nerves  even  thirty-six  hours  after  death.  I 
am  very  sceptical,  Gentlemen,  as  to  the  value  of  that  red- 
ness and  induration  of  the  nervous  tissue.  Even  admitting 
that  such  an  investigation  might  be  successful  twenty-four 
hours  after  death,  it  would  be  quite  useless  to  look  for  it 
four  or  five  days  after  death,  and  I  have  told  you  more  than 
once  already  that  medico-legal  autopsies  are  seldom  ordered 
immediately  after  the  individual  has  met  with  a  suspicious 
death. 

Therefore,  as  regards  the  diagnosis  of  sudden  death  from 
angina  pectoris,  we  have  no  positive  basis  in  morbid 
anatomy  ;  cases  of  this  sort  must  be  placed  in  the  category 
of  sudden  deaths,  of  which  it  is  sometimes  impossible  for 
us  to  give  an  exact  explanation  in  our  medico-legal  reports, 
and  such  cases  are  far  from  being  rare. 

G.  Neoplasms  of  the  Heart.  —  Before  concluding  the 
subject  of  lesions  of  the  heart,  I  ought  to  say  a  few  words 
about  new  growths  of  the  wall  of  the  heart,  which  have  in 
exceptional  cases  caused  sudden  death. 

I  will  content  myself  with  mentioning  tuberculosis  of  the 
septum  and  of  the  walls  of  the  ventricles,  a  case  of  which 
has  been  observed  by  Dr.  Southwood  Smith  ;  cancer  of 
the  cardiac  wall,  of  vv^hich  one  case  has  been  observed  by 
Segalas,  in  a  child  of  11  years  old,  and  another  by  M. 
Laudouzy  and  myself  in  a  woman  26  years  of  age  ;  and 
hydatids. 


I40  SUDDEN  DEATH. 


It  has  been  said  that  hydatids  have  a  preference  for  the 
right  ventricle  ;  Richard  Smith  and  Depaul  each  found  one 
in  the  interventricular  septum  ;  cases  have  been  reported  in 
which  the  cysts  have  ruptured  and  discharged  secondary 
cysts. 

Gentlemen,  allow  me  to  tell  you  of  a  post-mortem  in 
which,  on  opening  the  heart,  we  thought  we  had  to  deal 
with  a  hydatid  cyst  that  had  burst  into  the  right  ventricle. 
Microscopical  examination  did  not  confirm  the  diagnosis 
made  by  the  naked  eye.  We  found  instead,  little  cubes  full 
of  fibrin,  in  the  midst  of  which  were  red  corpuscles  more  or 
less  degenerated. 

I  cannot  tell  you  what  these  little  cubes  were  or  how  they 
were  produced,  although  I  know  of  two  similar  cases ;  but 
I  can  state  confidently  that  you  will  not  be  able,  in  a  case 
that  ends  in  sudden  death,  to  make  a  diagnosis  of  cancer 
of  the  ventricles  during  life,  any  more  than  that  of  hydatid 
cysts. 

II.  LESIONS  OF  THE  ARTERIES. 

'A  man  is  as  old  as  his  arteries'  is  an  aphorism  which 
has,  I  think,  been  attributed  to  Cazalis,  but  which  I  now 
know  to  be  much  more  ancient ;  from  the  point  of  view 
of  sudden  death,  it  is  absolutely  exact.  A  man  actually 
is  as  old  as  his  arteries.  Of  all  diseases  of  the  arteries, 
fibroid  degeneration  (arterio-sclerosis)  concerns  us  most ; 
it  may  manifest  itself  even  in  young  people.  Before 
entering  upon  the  study,  it  will  be  convenient  to  turn  our 
attention  first  to  the  congenital  arterial  lesions  which  may 
lead  to  sudden  death. 

A.  Congenital  Lesions. — One  of  these  lesions,  contraction 
of  the  aortic  orifice  and  narrowing  of  the  aorta,  has  been  demon- 
strated by  Virchow.  M.  Lesser,  of  Breslau,  has  studied  it 
afresh,  and  has  found  that  the  aorta  had,  in  subjects  of  this 
malformation,  who  were  20  or  22  years  of  age,  the  size  of  that 
of  a  child  of  8  or  10  ;  like  Virchow,  he  has  founded  a  theory  of 
chlorosis  upon  it.  I  have  not  ventured  to  discuss  chlorosis 
here  ;  it  is  evident  that  the  arterial  circulation,  and  conse- 


LESIONS  OF  THE  CIRCULATORY  SYSTEM.  141 


quently  nutrition,  must  be  defective  when  the  caUbre  of  the 
aorta  is  so  much  reduced,  and  it  may  produce  a  pecuHar 
form  of  anaemia. 

Virchovv  only  goes  so  far  as  to  say  that  narrowing  of  the 
aorta  might  at  a  given  moment  cause  sudden  death. 
M.  Lesser,  deducing  his  results  from  the  events  observed  in 
certain  diseases,  goes  further,  and  asserts  it  as  a  fact.  It  is 
necessary,  therefore,  when  one  has  to  do  with  sudden  death 
in  young  adults,  to  measure  the  size  of  the  aorta. 

It  is  to  a  congenital  malformation  of  another  sort  that 
the  following  case  of  sudden  death  must  be  ascribed  ;*  it 
made  a  great  impression  on  me.  I  believe  it  is  a  unique 
case,  and  the  one  that  most  closely  resembles  it  is  a  case 
recorded  by  Laennec  : 

A  medical  student,  20  years  of  age,  who  had  spent  the 
whole  of  the  afternoon  in  the  dissecting-room,  went  home 
by  rail  to  Perreux,  where  his  family  resided.  He  dined, 
and  afterwards  played  at  cards  with  his  parents  and  sisters. 
The  family  retired  at  10  o'clock ;  he  himself  went  to  his 
room,  wrote  a  letter  of  six  pages  to  a  friend,  and  then  went 
to  bed.  In  the  middle  of  the  night  his  mother  heard  her 
son  walking  about,  and,  thinking  that  he  was  ill,  rose  and 
found  him  complainmg  of  excruciating  pain  in  the  right  side 
of  his  chest.  A  physician  was  fetched,  who  thought  he  had 
to  deal  with  a  case  of  biliary  colic,  and  gave  an  injection 
of  morphine.  Mind,  I  am  not  finding  any  fault  with  this 
physician's  diagnosis.  The  pain  lasted  throughout  the  next 
day,  and  at  7  p.m.  the  young  man  died.  The  father  asked 
for  an  autopsy,  and  I  was  appointed  to  make  it.  In  the 
right  pleura  I  found  about  7  oz.  of  non-coagulated  blood, 
the  parietal  pleura  was  separated  from  the  ribs,  from  the 
third  rib  to  the  diaphragm,  and  there  was  thus  formed  a  sac 
containing  more  than  63  oz.  of  liquid  ;  the  mediastinum  was 
full  of  blood,  the  aorta  was  surrounded  by  an  effusion  of 
blood  which  reached  up  to  the  retropharyngeal  cellular  tissue 
and  descended  to  the  commencement  of  the  femoral  artery; 
the  posterior  third   of  the  mediastinum  was  full  of  blood  ; 

*  Brouardel  et  Vibert,   '  Rupture  de  I'Aorte  thoracique  chez  un  jeune 
Homme  de  Vingt  Ans'  {Ann.  d'Hyg.,  1892,  tome  xxvii.,  p.  450). 


142  SUDDEN  DEATH. 


the  aorta  was  ruptured  in  two  places ;  there  was  one  trans- 
verse laceration,  nearly  half  an  inch  long,  a  little  way  beyond 
the  origin  of  the  carotid,  and  a  second  tear,  almost  identical 
with  the  first,  about  an  inch  above  the  diaphragm. 

The  aorta  was  not  atheromatous,  but  its  walls  were  like 
paper,  owing  to  the  atrophy  of  the  middle  coat ;  the  muscular 
and  elastic  fibres  had  disappeared  ;  the  vessel  was  narrow, 
and  small  also.  The  young  man  had  had  typhoid  fever  when 
15  years  of  age.  Was  the  arterial  lesion  a  result  of  the  fever, 
or  was  it  congenital  ?  He  had  never  suffered  from  any  pain 
that  might  retrospectively  be  attributed  to  this  lesion ;  he 
had  practised  gymnastics,  had  ridden  a  bicycle,  and  had 
not  deprived  himself  of  any  of  the  pleasures  of  his  age  ;  in 
this  particular  case  the  rupture  of  the  aorta  had  not  been 
preceded  by  any  fall,  struggle,  or  any  sort  of  violence. 

There  is  here  something  very  interesting,  but  which  is 
very  little  known,  perhaps  because  in  the  majority  of  these 
cases  death  does  not  seem  to  present  any  characters  by 
which  it  might  have  been  suspected,  and  because  an  autopsy 
is  neither  demanded  by  the  friends  nor  insisted  on  by  law. 

B.  Arterio-sclerosis.*  —  Arteriosclerosis  causes  sudden 
death  more  often  than  any  other  arterial  lesion.  The  name 
denotes  a  particular  degeneration  of  the  walls  of  the  arteries, 
which  begins  generally  at  the  arch  of  the  aorta,  and  may 
then  spread  so  far  as  to  involve  the  whole  arterial  system ; 
it  has,  however,  two  seats  of  election,  viz.,  the  arteries  of 
the  brain  and  of  the  kidneys.  This  generalization  and  pre- 
dilection concern  us  equally.  When  an  artery  has  under- 
gone this  change,  its  walls  become  fragile  and  friable,  and 
its  calibre  is  diminished,  and  may  even  be  obliterated. 

Fragility  of  the  walls  tends  to  produce  rupture  of  the 
artery.  Any  artery  may  rupture.  Rupture  of  the  aorta  is 
nearly  always  determined  by  an  accident,  such  as  a  struggle, 
a  rather  heavy  fall,  or  a  dispute — circumstances  which  all 
call  for  the  intervention  of  the  law,  which  attributes  the 
death  to  violence.     At  the  autopsy  there  is  found  a  lacera- 

*  The  term  arterio-sclerose.,  used  in  the  original,  is  translated  literally 
to  denote  a  morbid  condition  of  the  arteries  for  which  there  is  at  present 
no  well-recognized  name  in  English,  though  such  a  term  is  wanted. — Tr. 


LESIONS  OF  THE  CIRCULATORY  SYSTEM.  143 

tion  of  the  aorta,  sometimes  completely  through  the  wall, 
sometimes  incomplete,  with  separation  of  the  cellular  coat, 
and  a  second  tear  a  little  lower  ('  dissecting  aneurysm  '  of 
Laennec).  The  coronary  arteries  may  rupture  likewise  and 
give  rise  to  hemorrhage  into  the  pericardium.  Along  wath 
fragility  of  the  w^alls,  we  must  take  notice  of  their  hyper- 
trophy, which  lessens  the  calibre  of  the  artery  and  no  longer 
permits  the  normal  amount  of  blood  to  reach  the  neighbour- 
ing tissues.  This  point  is  chiefly  of  importance  with  regard 
to  the  brain,  where  there  are  but  few  anastomoses,  and 
where  the  diminished  supply  of  blood  immediately  induces 
anemia,  which  manifests  itself  as  hemiplegia,  such  as  was 
called  '  temporary  hemiplegia  '  by  Cruveilhier.  This  is  what 
happened  to  a  coachman,  who  all  at  once  let  his  whip  fall, 
and  who  was  carried  to  the  hospital  with  one  side  of  his 
body  paralysed,  though  he  recovered  his  senses  and  the  use 
of  his  limbs  after  a  few  days'  rest. 

These  accidents  may  be  met  with  even  in  individuals  who 
are  not  the  subjects  of  generalized  arterio-sclerosis  ;  aphasia 
and  hemiplegia  are  sometimes  due  to  cerebral  arterio- 
sclerosis, which  may  remain  localized  for  a  long  time.  When 
the  blood-supply  is  not  merely  irregular,  but  completely 
shut  off,  it  forms  a  focus  of  softening  in  the  part  which  is 
no  longer  nourished,  and  this  leads  to  death,  sooner  or  later, 
according  to  the  region  implicated.  From  the  point  of  view 
of  sudden  death,  the  vessel  that  concerns  us  most  is  the 
basilar  artery,  which  is  formed  by  the  union  of  the  two 
vertebral  arteries,  and  which  supplies  by  its  branches  the 
medulla  and  pons. 

I  know  of  about  35  reported  cases  of  thrombosis  of 
the  basilar  artery.  The  symptoms  occur  very  much  as  in 
the  following  case,  which  may  serve  as  a  typical  example : 
A  man,  aged  50,  felt  unwell ;  as  he  was  walking  along  the 
boulevard,  he  entered  a  cafe  to  rest  ;  he  sat  down  and  could 
no  longer  speak  ;  he  had  not  aphasia,  however,  but  paralysis 
of  the  hypoglossal  nerve.  He  was  taken  to  the  hospital, 
whence  he  was  discharged  temporarily  cured. 

When  the  obliteration  is  immediate  and  complete,  death 
may  supervene    suddenly  in    a    few  minutes;    there    is  an 


144  SUDDEN  DEATH. 


abrupt  stoppage  of  all  the  vital  phenomena,  just  as  if  the 
'  vital  knot  '  of  Flourens  had  been  divided. 

C.  Aneurysms. — Arterio-sclerosis  may  lead  to  the  forma- 
tion of  aneurysms  of  the  great  arterial  trunks. 

Aneurysms  of  the  aorta  often  take  us  by  surprise  in 
making  an  autopsy.  They  may  escape  notice  altogether 
during  life,  especially  if  the  pneumogastric  nerve  is  not  in- 
volved in  the  aneurysmal  sac,  and  if  the  bronchi  are  not  too 
much  compressed.  A  professor  of  this  faculty  was  one  of 
the  most  fervent  believers  in  the  doctrine  of  'the  arthritic 
diathesis.'  He  said  that  he  himself  was  the  subject  of  this 
diathesis,  and  attributed  thereto  the  violent  pains  that  he 
felt  in  the  back  and  in  the  chest.  He  was  suddenly  seized 
during  the  night  with  a  violent  fatal  haemorrhage  from  the 
air-passages.  He  had  an  aortic  aneurysm,  though  its  exist- 
ence was  totally  unknown  to  himself  and  to  his  friends  who 
had  examined  him,  and  it  had  burst. 

Aneurysms  of  the  aorta  which  eat  their  way  through  the 
ribs,  and  reach  the  surface  of  the  chest,  rarely  give  occasion 
for  medico-legal  investigations  ;  but  when  they  burst  into 
neighbouring  organs  it  is  otherwise.  These  aneurysms  may 
actually  open  into  the  spinal  canal  after  having  eroded  the 
vertebrse,  into  the  bronchi,  or  the  pleurae.  I  know  of  two 
cases  of  aneurysm  of  the  aorta  which  led  to  an  inquest 
being  held.  They  were  aneurysms  of  the  abdominal  aorta, 
and  death,  attended  by  vomiting  and  coldness  of  the  extremi- 
ties, was  attributed  to  poison. 

Those  little  aneurysms  which  arise  from  the  commence- 
ment of  the  aorta,  where  it  is  still  within  the  pericardium, 
may  burst  into  the  pericardial  sac,  and  lead  to  death  as 
rapidly  as  does  rupture  of  the  heart. 

I  shall  not  speak  to  you  of  aneurysms  of  all  the  arteries. 
I  must,  however,  mention  those  of  the  large  arteries  of  the 
brain,  and  especially  those  of  the  basilar  artery.  I  will  add 
that  the  arteries  of  the  brain  may  be  affected  with  arterio- 
sclerosis though  all  other  arteries  in  the  body  may  be 
sound. 

It  is  usually  the  suddenness  of  these  affairs  which  leads  to 
a    medico-legal    inquiry.     But   the   opposite   case    happens 


LESIONS  OF  THE  CIRCULATORY  SYSTEM.  145 


sometimes.  I  was  directed  one  day  to  make  an  autopsy  on 
an  old  cachectic  woman,  who  had  a  large  bedsore  over  the 
sacrum,  and  who  died  in  the  last  stage  of  exhaustion.  The 
medical  verifier  of  death,  seeing  that  the  trunk  and  limbs 
were  covered  with  ecchymoses,  refused  permission  for  burial. 
At  the  autopsy  I  found  general  arterio-sclerosis,  with  an 
aneurysm  of  the  aorta,  which  had  burst  into  the  left  pleura. 
A  certain  number  of  individuals  exist  in  whom  ecchymoses 
are  produced  with  almost  incredible  facility ;  these  are  the 
subjects  of  general  arterio-sclerosis.  The  slightest  violence, 
the  least  effort,  even  the  effort  of  pressing  strongly  on  the 
handle  of  a  door  that  they  are  trying  to  open,  is  sufficient  in 
such  persons  as  these  to  produce  ecchymoses.  I  should  not 
like  to  terminate  this  rapid  review  of  arterial  lesions  capable 
of  inducing  sudden  death,  without  speaking  of  rupture  of  the 
pulmonary  artery.  The  fact  has  been  observed  once  by 
Devergie  ;  he  has  given  us  a  very  abbreviated  description  of 
the  case ;  and  for  my  part  I  do  not  know  to  what  to  attri- 
bute the  rupture. 

III.    LESIONS  OF  THE  VEINS. 

Lesions  of  the  veins  are  not  generally  considered  to  be  a 
frequent  cause  of  sudden  death.  Nevertheless  such  in- 
stances are  not  rare. 

A.  Rupture  of  Veins. — Veins  may  burst.  Portal  has 
described  rupture  of  the  pulmonary  vein  where  it  opens 
into  the  left  auricle.  Morgagni  has  related,  with  abundant 
details,  a  case  of  rupture  of  the  vena  azygos  into  the 
right  pleura,  which  contained  4  lbs.  of  blood  ;  the  an- 
atomical specimen  prepared  by  him  is  still  to  be  seen  in 
the  museum  at  Padua.  This  rupture  of  the  azygos  vein 
happened  in  a  tuberculous  girl  as  a  result  of  a  violent  fit  of 
coughing.  Andral  has  mentioned  a  case  of  rupture  of  the 
vena  cava  inferior  in  a  young  man  who  had  been  wrestling 
with  one  of  his  comrades,  without  the  wrestling  having  at 
all  amounted  to  a  violent  struggle. 

B.  Thrombosis  and  Embolism. — The  lesions  of  the  veins 
which,  beyond  any  doubt,  provoke  the  largest  number  of 
sudden  deaths  are  thrombosis  and  embolism  of  the  pulmonary 

10 


146  SUDDEN  DEATH. 


artery.  Chief  among  the  varieties  of  thrombosis  which 
lead  to  sudden  death,  I  should  place  inflamed  varicose 
veins. 

Individuals  who  die  under  these  conditions  do  so  because 
the  clot  coming  from  an  inflamed  varicose  vein  has  been  dis- 
charged into  the  stream  of  the  circulation,  and  has  blocked 
one  of  the  branches  of  the  pulmonary  artery.  Such  an 
accident  does  not  usually  call  for  an  inquest,  though  excep- 
tions are  not  very  rare. 

Some  years  ago  a  professor  of  this  Faculty  died  suddenly. 
His  brother-in-law  wished  to  undertake  all  the  necessary 
duties,  and  you  know  how  numerous  they  are.  He  followed 
the  body  on  foot  in  the  procession  to  the  cemetery.  He  was 
very  tired  when  he  returned,  and  almost  immediately  was 
seized  with  great  difficulty  of  breathing  ;  he  would  not  take 
any  rest,  however,  and  although  he  was  no  better  the  next 
day,  he  received  many  visits.  Another  attack  of  dyspnoea 
came  on,  and  he  died  in  it.  He  had  varicose  veins,  which 
became  inflamed  in  consequence  of  the  fatigue  which  he  had 
incurred  during  the  last  few  days,  and  clots  detached  from 
the  inflamed  vein  had  been  carried  to  the  lung,  where  they 
had  caused  a  blocking  of  the  artery,  which  ended  fatally. 

The  same  phenomena  occur  also  in  phlegmasia  alba 
dolens.  The  clots  found  in  the  femoral  and  iliac  veins,  as. 
well  as  in  the  uterine  veins,  extend  into  the  vena  cava 
inferior.  If  the  clot  gets  dislodged,  it  enters  the  pulmonary 
circulation  as  an  embolus,  and  if  this  is  large  the  patient 
dies. 

It  is  not  only  in  lying-in  women  that  such  accidents  may 
happen.  It  is  essential  that  you  should  know  that  even 
before  confinement  the  peri-uterine  veins  may  be  the  seat  of 
thrombosis,  which  only  attracts  attention  when  the  inflam- 
mation spreads  to  the  superficial  veins.  Women  suffering 
from  phlebitis  are  often  allowed  to  walk  about  too  soon. 
Out  of  150  cases  of  sudden  death  due  to  displacement  of 
blood-clots,  death  happened  112  times  in  the  first  two  or 
three  weeks  after  the  thrombosis  began.  After  this  time, 
if  it  is  dislodged,  it  is  in  the  form  of  a  number  of  small  clots, 
instead  of  a  single  large  one,  which  enter  the  pulmonary 


LESIONS  OF  THE  CIRCULATORY  SYSTEM.  147 

circulation  and  produce  embolism  of  less  gravity.  The 
results  of  these  are  infarcts  and  hemoptysis,  and  the  woman 
only  dies  if  too  little  of  the  pulmonary  area  remains. 

When  there  is  a  fibroid  tum.our  of  the  uterus,  the  veins 
and  uterine  sinuses  may  be  attacked  in  like  manner ;  and  in 
other  ways  uterine  fibroids  are  often  accompanied  by  pheno- 
mena resembling  those  of  confinement.^  It  is  necessary, 
therefore,  to  adopt  similar  treatment  in  cases  of  fibroid 
tumours  to  that  of  lying-in  women,  and  to  take  similar  pre- 
cautions.    I  will  say  the  same  of  ovarian  cysts. 

Thrombosis  and  embolism  may  take  place  in  cachexia, 
such  as  that  of  phthisis  or  cancer,  as  you  know.  The 
patient  may  be  sitting  up  in  bed,  eating,  or  obeying  the  calls 
of  nature,  when  all  at  once  he  feels  suffocated  and  drops 
down  dead.  These  accidents  are  particularly  prone  to 
happen  in  the  case  of  cancerous  growths  affecting  certain 
organs,  where  they  may  remain  latent  for  some  time  ;  these 
are,  cancer  of  the  breast,  which  induces  thrombosis  of  the 
axillary  vein,  cancer  of  the  womb,  before  haemorrhage  has 
called  attention  to  it,  and  cancer  of  the  prostate. 

Among  these  forms  of  venous  thrombosis  I  shall  place 
caries  of  the  petrous  portion  of  the  temporal  bone,  which 
follows  inflammation  of  the  middle  ear.  Toynbee  has  shown 
that  the  circulation  in  the  brain  or  meninges  is  connected 
by  numerous  anastomoses  with  that  of  the  middle  ear. 
Thrombosis  of  the  sinuses,  especially  of  the  lateral  sinus, 
may  be  the  consequence  of  otitis.  When  otitis  exists,  and 
the  physician  or  surgeon  fears  that  caries  of  the  petrous 
portion  may  supervene,  it  is  necessary  to  remember  that 
sudden  death  may  occur.  The  clots  may  be  in  existence  a 
long  while  without  attracting  attention. 

Here  is  an  instance  :  A  man,  36  years  of  age,  who  had 
inflammation  of  the  middle  ear  in  December  and  January, 
but  which  had  been  neglected,  went  to  dine  with  his  sister 
one  day  in  the  following  June,  without  having  sought  the 
advice  of  a  physician.  There  was  music  after  dinner,  and 
he  played  the  violoncello.     He  was  seized  all  at  once  with  a 

*  Bastard,  '  Des  Thromboses  veineuses  dans  les  Corps  fibreux  de 
rUterus.'     These  inaugurale,  1882. 


SUDDEN  DEATH. 


terrible  feeling  of  suffocation,  and  died.  At  the  autopsy  a  large 
clot  was  found  in  the  pulmonar}'  artery,  which  corresponded 
exactly  with  the  main  portion,  which  was  situated  in  the 
lateral  sinus,  and  whence  it  had  become  detached,  without 
the  deceased  having  made  any  effort  or  violent  movement. 

Similar  occurrences  have  been  met  with  in  the  laier  stages 
of  typhoid  fever. 

The  same  thing  may  follow  boils  on  the  face,  especially 
those  on  the  lips.  A  Danish  physician,  Dr.  Ch.  Trude, 
has  particularly  called  attention  to  this  complication.  In 
these  cases  there  is  often  produced  an  inflammation  of  the 
veins  of  the  face,  which  may  spread  to  the  cerebral  sinuses 
and  give  rise  to  thrombosis.  I  ought  to  mention  that  all 
examples  of  this  w'ere  observed  before  the  introduction  of 
the  antiseptic  method  into  surgery.  They  are  therefore 
probably  due  to  infection,  for  they  have  not  been  witnessed 
since.  I  remember  that  when  I  was  physician  to  the  St. 
Antoine  Hospital,  I  saw  in  consultation  with  M.  Duplay, 
one  of  the  surgeons  to  the  hospital,  a  foreigner  who  had 
been  admitted  ;  he  had  a  well-marked  dermatitis  of  the  face, 
which  might  have  been  mistaken  for  erysipelas,  nasal 
catarrh,  and  giddiness  ;  and  he  had  become  blind.  Our 
diagnosis  was  '  inflammation  of  the  sinuses  of  the  dura 
mater,'  and  the  autopsy  proved  that  we  were  correct. 

In  Germany  four  or  five  cases  of  sudden  death  have  been 
observed  in  the  course  of  gonorrhoea  in  the  male;  I  only 
know  of  one  case  in  France ;  at  the  inquest  it  was  shown 
that  there  had  been  phlebitis  of  the  sinuses  of  the  prostate, 
and  that  a  clot  was  carried  thence  into  the  pulmonary  circu- 
lation.    Death  was  due  to  embolism. 

I  made  an  autopsy  on  a  young  girl,  sixteen  years  of  age, 
whose  mother  had  a  lover.  To  attach  this  man  to  her  still 
miore,  the  mother  gave  him  her  daughter.  The  latter  con- 
tracted gonorrhoea,  which  led  to  inflammation  of  the  veins 
of  the  broad  ligaments ;  there  was  thrombosis  of  the  left 
iliac  vein.  While  sitting  on  her  bed,  taking  some  soup, 
embolism  occurred,  which  carried  her  off;  the  remainder  of 
the  clot  was  found  in  the  iliac  vein. 

Sudden  death  after  a  fracture  or  dislocation  may  be  caused 


LESIONS  OF  THE  CIRCULATORY  SYSTEM.  149 

by  thrombosis  of  the  veins  which  are  in  direct  relation  with 
the  seat  of  fracture  or  dislocation.  This  complication  has 
been  described  by  xA.zam  of  Bordeaux.* 

It  is  more  frequent  in  injuries  of  the  lower  than  of  the 
upper  limbs.  It  is  interesting  for  several  reasons :  when 
the  surgeon  is  reducing  the  fracture  or  dislocation,  he  can- 
not at  first  recognize  the  existence  of  thrombosis,  and 
ascribes  the  swelling  directly  to  the  injury,  and  not  to  the 
thrombosis  which  is  the  consequence  of  it ;  then  he  may 
be  blamed  if  he  has  given  chloroform  to  set  the  fracture  or 
reduce  the  dislocation  ;  in  such  cases  death  due  simply  to 
embolism  has  sometimes  been  ascribed  to  the  chloroform. 
I  could  tell  you  of  the  case  of  a  provincial  surgeon  who  was 
actually  found  guilty  of  homicide  through  want  of  care. 
And  yet,  when  we  think  of  the  number  of  patients  who 
died  before,  during  and  after  an  operation,  before  chloro- 
form was  introduced  into  practice,  we  are  not  a  little 
astonished  at  the  small  number  of  accidents  which  have 
to  be  put  to  the  account  of  the  ansesthetics,  ether  and 
chloroform. 

I  shall  conclude  this  medico-legal  study  of  sudden  death 
from  embolism  by  relating  to  you  the  following  case,  which 
shows  in  what  manner  you  may  be  called  upon  to  give 
evidence  : 

Some  years  ago,  at  Nanterre,  a  house  inhabited  by  an 
old  couple  was  found  shut  up  one  morning.  The  neigh- 
bours were  uneasy,  and  informed  the  son,  who  lived  in  Paris. 
He  arrived,  and  went  into  the  house.  There  he  found  his 
father  dead,  in  his  shirt,  lying  on  his  back  in  bed,  with  his 
feet  on  the  floor.  He  looked  for  his  mother,  and  found  her 
dead  also,  at  the  bottom  of  a  flight  of  steps  leading  down 
to  the  cellar  ;  a  candlestick  was  by  her  side.  The  law  was 
properly  set  in  motion  to  investigate  these  two  deaths,  and 
an  inquest  was  ordered.  The  autopsy  revealed  the  fact  that 
the  old  man  had  cancer  of  the  prostate,  thrombosis  of  the 
sinuses,    and    a    large    embolus    in    the    pulmonary  artery. 

*  Azani,  '  De  la  Mort  subite  par  Embolie  pulmonaire  dans  les  Con- 
tusions et  les  Fractures'  (Bi^//.  de  PAcad.  de  Med..,  1864,  tome  xxix,, 
p.  816). 


SUDDEN  DEATH. 


The  woman  had  a  fracture  of  the  sixth  cervical  vertebra, 
and  haemorrhage  into  the  spinal  cord.  From  these  data  it 
was  easy  to  reconstruct  the  scene. 

On  entering  the  old  man's  room,  there  was  evidence  that 
a  meal  had  been  going  on,  and  that  the  bottle  placed  on  the 
table  was  empty.  The  woman  had  lighted  a  candle  in  order 
to  go  and  fetch  some  wine  from  the  cellar  ;  she  had  slipped 
on  the  stairs  and  broken  her  spine ;  the  noise  of  her  fall 
and  the  cry  she  must  have  uttered  roused  her  husband  to 
jump  off  his  bed  and  hasten  to  help  her.  The  effort  was 
too  sudden  or  the  excitement  too  much  for  him.  Directly 
his  feet  touched  the  ground  an  embolus  was  detached  from 
the  prostatic  sinuses,  and  he  died. 

Gentlemen,  when  you  have  to  search  for  the  cause  of 
sudden  death,  and  you  have  reason  to  believe  that  it  may 
be  due  to  embolism,  do  not  conduct  the  autopsy  according 
to  the  usual  manner  in  which  it  is  performed  in  the  hospital. 

At  the  hospital  you  are  especially  desirous  of  verifying 
the  accuracy  of  your  diagnosis,  therefore  you  open  the 
thorax  and  remove  the  organs  contained  in  it,  so  as  to 
examine  them  with  greater  ease.  If  you  proceed  in  that 
way,  you  will  fail  to  find  the  embolus  you  are  looking  for ; 
the  clot  which  has  been  carried  into  the  pulmonary  artery 
obliterates  one  of  its  branches ;  there  is  formed  behind  it  a 
more  or  less  long  coagulum  ;  and  if,  in  order  to  remove  the 
thoracic  organs,  you  pull  on  the  larynx  and  trachea,  you 
change  the  relations  of  the  parts,  displace  the  clot,  and  will 
not  find  it  in  situ. 

Instead  of  this,  open  the  chest  freely,  open  the  pericar- 
dium and  dissect  the  heart  in  situ,  feel  with  your  finger  for 
the  clots  formed  during  the  last  hours  of  life,  which  you  will 
be  able  to  remove  easily ;  follow  the  ramifications  of  the 
pulmonary  artery  ;  if  there  is  an  embolus,  you  will  find  it 
without  difficulty,  and  you  will  be  able  to  compare  the 
broken  surface  of  the  clot  thrown  into  the  blood-stream 
with  the  remainder  of  it  left  in  the  vein  where  the  thrombus 
was  formed. 

C.  Air  in  the  Veins. — Allied  to  this  subject  of  sudden 
death   by   embolism   is   another,    which    has    occupied    the 


LESIONS  OF  THE  CIRCULATORY  SYSTEM.  151 

attention  of  former  generations  for  a  long  time,  and  about 
which  I  must  say  a  few  words.  The  two  Berards  (especially 
the  surgeon),  Dupuytren,  and  others  also  had  noticed  that 
in  cases  of  wounds  of  the  neck,  when  the  wounded  man 
made  any  effort,  air  might  enter  the  veins  implicated  in  the 
wound,  producing  a  peculiar  hissing  sound  as  it  did  so,  and 
that  the  individual  died  almost  immediately.  This  was 
certainly  a  sudden  death. 

You  know  that  the  aponeuroses  of  the  neck  form  a  sort 
of  framework,  the  meshes  of  which  keep  the  jugular  veins 
patent.  If  one  of  these  veins  is  opened,  the  air  may  enter 
it ;  this  air  mixes  with  the  blood  in  the  form  of  bubbles  and 
blocks  the  capillaries  ;  it  is  like  a  plug  of  gas,  which  plays 
the  same  part  as  a  clot,  and  which  brings  about  sudden 
death.     This  is  an  exact  statement. 

But  the  theory  of  sudden  death  due  to  the  entrance  of 
air  into  the  veins  has  been  peculiarly  extended  in  its  appli- 
cation. The  uterine  sinuses  have  been  considered  to  be 
included  within  its  scope.  It  has  been  thought  that  entrance 
of  air  into  the  uterine  sinuses  might  give  rise  to  sudden 
death,  and  that  in  some  cases  of  abortion  death  might  be 
due  thereto. 

Gentlemen,  examine  the  documents  published  on  this 
question  ;  you  will  be  astonished  at  the  readiness  with  which 
facts  are  adapted  to  any  theory  which  is  fashionable  at  the 
moment.  And  this  theory,  in  as  far  as  it  deals  with  the 
uterine  sinuses,  cannot  be  accepted.  As  a  matter  of  fact, 
during  confinement,  if  the  sinuses  are  gaping,  there  must  be 
haemorrhage,  and  consequently  the  entrance  of  air  into  the 
circulation  is  difficult ;  if  the  uterus  is  contracted,  the  sinuses 
are  closed  up,  and  their  canal  is  obliterated.  In  abortion 
these  sinuses  can  scarcely  be  patent. 

Well,  this  theory  reigned  for  more  than  fifteen  years, 
and  has  been  supported  by  the  most  eminent  and  scientific 
men.  It  was  founded  mainly  on  two  cases.  The  first  was 
observed  by  Depaul  in  the  Lying-in  Hospital.  A  pregnant 
woman  who  had  a  deformed  pelvis  was  admitted  into  the 
hospital.  It  was  necessary  to  induce  premature  labour, 
and    several    instruments  were  passed   into  the    uterus    for 


152  SUDDEN  DEATH. 


that  purpose.  The  woman  died  without  having  been  de- 
livered. Depaul  resolved  to  perform  Csesarean  section 
post-mortem.  He  opened  the  woman's  abdomen,  and  found, 
as  soon  as  he  incised  the  uterus,  that  air  escaped  from  the 
uterine  vessels. 

The  record  of  this  very  interesting  case  ought  to  be  pre- 
served. I  do  not  know  what  explanation  to  give  of  it ;  but 
it  does  not  prove  that  air  enters  the  vessels,  for  the  placenta 
was  not  separated  and  the  veins  were  not  open. 

The  second  case  is  as  follows  :  A  little  operation  had  been 
performed  on  a  body  which  was  going  to  be  submitted  to  a 
post-mortem  examination,  although  leave  to  do  so  had  not 
yet  been  obtained.  The  operation  consisted  in  tying  one  or 
more  veins  at  two  points  of  their  course.  At  the  autopsy, 
on  cutting  these  veins  between  the  ligatures,  gas  was  noticed 
to  escape. 

This  is  a  simple  example  of  putrefaction,  which  is  ex- 
plained by  the  succession  of  aerobic,  amphibious,  and 
anaerobic  colonies,  and  the  gases  they  produce. 

Observe  that  from  the  day  on  which  the  discussion  on 
the  theory  of  entrance  of  air  into  the  veins  took  place,  no 
one  else  has  published  any  cases  of  the  kind.  Now,  that 
happened  in  1859  or  i860.  When,  during  the  course  of 
twenty  or  thirty  consecutive  years,  there  has  not  been  a 
single  instance  of  a  condition  which  seemed  to  be  very 
common  before,  there  is  good  reason  to  believe  that  the 
facts  have  been  wrongly  interpreted,  and  that  the  conclu- 
sions which  had  been  drawn  from  them  were  false. 

I  do  not  say  that  there  never  can  be  any  gas  in  the  blood; 
it  may  be  there  in  cases  like  those  of  Dr.  Parise,  of  Lille, 
who  has  twice  seen  gas  escape  from  the  wound  at  the  same 
time  as  the  blood,  while  performing  venesection  ;  but  his 
patients  were  suffering  from  gangrene,  and  the  gangrene 
was  of  that  intense  kind  which  is  apt  to  follow  bites, 
especially  rat-bites ;  he  therefore  met  with  phenomena  of 
putrefaction  during  life. 

It  may  happen  also  in  the  case  of  navvies  who  have  to 
work  in  compressed  air.  You  know  that,  in  order  to  con- 
struct certain  works — fixing  the  piles  of  a  bridge,  for  example 


LESIONS  OF  THE  CIRCULATORY  SYSTEM.  153 

— the  labourers  are  obliged  to  work  in  diving-bells  filled  with 
compressed  air.  Nowadays  the  pressure  seldom  exceeds 
two  atmospheres ;  formerly  it  was  not  so ;  this  degree  was 
far  exceeded,  and  no  precaution  was  taken  at  the  moment 
when  the  workmen  came  out  of  the  bell,  and  under  those 
conditions  accidents  were  numerous.  They  were  particu- 
larly common  during  the  construction  of  the  Bridge  of  Kehl, 
where  several  workmen  died  suddenly. 

The  mechanism  of  this  form  of  sudden  death  has  been 
demonstrated  in  the  case  of  those  who  have  been  recalled 
to  life.  One  of  these  men  was  completely  blind  in  one  eye. 
Ophthalmoscopic  examination  showed  that  the  ophthalmic 
artery  was  obliterated,  and  that  a  bubble  of  air  had  ob- 
structed the  artery  of  the  optic  nerve.  The  case  is  not  an 
isolated  one. 

When  compressed  air  is  absorbed  as  a  consequence  of 
respiration,  and  the  compression  is  abruptly  removed,  the 
air  tends  to  escape,  and  may  produce  plugs  of  gas  in  the 
bloodvessels,  which,  by  arresting  the  circulation  at  certain 
points,  may  cause  fatal  results. 

Workmen  are  less  exposed  to  these  dangers  nowadays 
than  formerly,  because  they  are  made  to  pass,  on  leaving 
the  diving-bell,  through  a  series  of  chambers  in  which  the 
atmospheric  pressure  is  reduced  by  degrees. 

IV.  LESIONS  OF  THE  CAPILLARIES. 

A.  Miliary  Aneurysms.  —  You  all  know  what  miliary 
aneurysms  are,  so  I  will  not  describe  them.  Their  favourite 
seats  are  the  brain  and  spinal  cord.  Charcot  and  Bouchard 
have  pointed  out  that  miliary  aneurysms  are  the  most 
common  cause  of  cerebral  haemorrhage. 

In  what  way  may  our  opinion  be  called  for,  from  a  medico- 
legal standpoint,  in  a  case  of  sudden  death  from  cerebral 
haemorrhage  ? 

I  have  told  you  that  we  very  rarely  have  to  make  medico- 
legal reports  after  attacks  of  apoplexy.  Death  is  only 
suspicious  in  certain  special  circumstances ;  for  example,  if 
the  deceased  had  not   reached  the  age  at  which   cerebral 


154  SUDDEN  DEATH. 


haemorrhage  usually  occurs^  or  if  it  is  attended  b}'  more  or 
less  unaccustomed  phenomena,  then  the  law  requires  an 
inquest  to  be  held. 

Miliary  aneurysms  are  most  common  in  aged  people,  yet 
children  of  2,  5,  6,  7,  or  11  years  of  age  sometimes  die  of  cere- 
bral hsemorrhage.  An  inquest  is  rendered  obligatory  in  such 
cases  as  these,  either  because  the  child  has  fallen  down,  or 
because  its  body  presents  ecchymoses,  or  especially  because 
the  public — which  has  not  much  knowledge  of  these  matters 
— attributes  the  accident  to  some  extraneous  cause. 

If  we  were  to  rely  only  on  the  statistics  obtained  from 
the  cases  collected  in  works  of  forensic  medicine,  we  should 
arrive  at  the  paradoxical  conclusion  that  cerebral  haemor- 
rhage is  more  common  in  the  bulb  than  in  the  rest  of 
the  brain.  As  far  as  that  goes,  I  can  quote  to  you  thirty 
or  more  cases  of  bulbar  hemorrhage,  which  have  been 
reported  because  they  are  hsemorrhages  of  an  unusual 
kind.  I  myself  have  only  met  with  two  such  cases — one  at 
the  Morgue,  the  other  in  my  private  practice — and  yet  I 
have  made  a  considerable  number  of  autopsies  in  my  life. 

Death  is  sudden  when  the  hsemorrhage  into  the  brain  is 
of  considerable  magnitude,  and  especially  when  the  blood 
has  found  its  way  into  the  lateral  ventricles.  The  amount 
of  blood  effused  varies  ;  it  may  amount  to  loi-  oz.  in  fulmi- 
nating apoplexy,  but  it  may  be  safely  said  that  recovery  is 
impossible  when  the  effusion  exceeds  7  to  g  oz. 

Allow  me  to  mention  to  you  three  cases  in  which  an 
inquest  was  held ;  they  will  enable  you  to  grasp,  in  a  some- 
what general  way,  the  reasons  for  your  interposition  as 
experts  in  cases  of  sudden  death  from  cerebral  haemorrhage : 

A  man  fell  down  in  the  street  in  a  seizure  due  to  cerebral 
haemorrhage ;  he  cut  his  head  on  the  kerb ;  no  one  witnessed 
the  scene.  The  body  was  found,  and,  as  there  was  a  wound, 
the  law  required  that  an  inquest  should  be  held.  At  the 
autopsy  it  was  demonstrated  that  this  individual  died  natur- 
ally of  haemorrhage  in  the  brain. 

Again,  a  woman  was  found  dead  at  the  foot  of  her  bed, 
with  a  wound  on  her  forehead  ;  her  chamber  utensil  was 
broken.     As  she  was  living  on  bad  terms  with  her  husband. 


LESIONS  OF  THE  CIRCULATORY  SYSTEM.  155 

he  was  accused  of  having  killed  her,  and  was  arrested.  The 
autopsy  showed  that  she  had  succumbed  to -a  hsemorrhage 
into  one  of  the  crura  cerebri.  Whether  she  had  been  over- 
come by  the  stroke  at  the  very  moment  that  she  was  about 
to  obey  a  natural  call  to  make  water,  or  whether,  on  the 
contrary,  she  had  been  first  struck  by  apoplexy,  and  under 
the  influence  of  the  stroke  had  executed  the  movement  of 
rotation,  which  is  commonly  seen  in  cases  of  haemorrhage 
into  the  crus,  and  consequently  had  fallen  off  the  bed,  I  do 
not  know;  in  any  case,  the  wound  was  only  the  result  of 
an  accident,  and  her  husband  v/as  acquitted. 

The  third  case  gave  rise,  in  the  last  century,  to  a  judicial 
error.  Two  individuals  were  arrested  at  Calais,  and  accused 
of  having  killed  their  mother.  The  first  medical  experts 
who  had  examined  the  body  had  indeed  remarked  that 
there  existed  in  this  woman  a  sub-epicranial  and  a  cerebral 
hsemorrhage.  As  the  two  sons  had  had  a  dispute  with 
their  mother,  they  were  immediately  accused  of  matricide. 
Louis  was  consulted.  Louis  had  for  a  long  time  been 
physician  to  the  Salpetriere,  and  was  aware  that  sub- 
epicranial  ecchymosis  is  a  very  frequent  occurrence  in  those 
who  are  struck  down  by  cerebral  hsemorrhage ;  he  declared 
that  the  woman  had  died  a  natural  death. 

There  is  nothing  that  ought  to  astonish  us  in  the  pro- 
duction of  sub-epicranial  ecchymosis,  which  was  thoroughly 
studied  by  Charcot  and  M.  Lepine  some  years  ago. 

In  cerebral  hsemorrhage,  ecchymosis  may  appear  under 
the  scalp,  or  in  the  pleurse,  stomach  or  liver.  There  is 
only  one  important  point  about  this  fact  which  it  is  neces- 
sary for  us  to  remember  :  we  ought  not  to  conclude,  when 
we  meet  with  ecchymosis  outside  the  skull  in  a  case  of  cere- 
bral hsemorrhage,  that  there  has  been  any  violence  at  all ; 
that  ecchymosis  may  be  produced  naturally  and  spontane- 
ously, as  a  consequence  of  the  stroke. 

When  a  lying-in  woman  dies  suddenly  from  cerebral 
hsemorrhage,  her  death  may  give  rise  to  a  medico-legal 
investigation ;  not  that  in  her  case  the  hsemorrhage  pre- 
sents any  symptoms  different  from  the  ordinary,  but  because 
sudden  death  in  a  lying-in  woman,  who  has  had  to  undergo 


i;6  SUDDEN  DEATH. 


certain  manipulations,  or  has  had  to  swallow  certain  medica- 
ments, astonishes  the  relatives  or  the  attendants,  who  ask 
whether  the  physician  is  not  responsible  for  the  catastrophe. 
If,  on  the  other  hand,  the  woman  has  had  no  medical  at- 
tendance, suspicion  of  an  induced  abortion  arises  at  once 
and  gives  cause  for  an  inquest. 

B.  Meningeal  Haemorrhages. — Meningeal  haemorrhages 
frequently  occasion  medico-legal  investigations.  You  know 
that  they  take  place  in  individuals  who  are  predisposed 
thereto  by  alcoholic  excess,  who  have  syphilitic  caries,  or 
who  are  insane.  As  an  effect  of  one  or  other  of  these 
conditions,  pachymeningitis  is  set  up,  which  leads  to  effusion 
of  blood  into  the  arachnoid  space.  Baillarger,  Longer, 
Virchow,  Lancereaux,  and  Cornil  have  studied  the  patho- 
logical anatomy  of  these  pachymeningites.  I  only  re- 
member at  this  moment  one  point  of  importance,  viz. :  that 
the  vessels  of  this  newly-formed  product  are  extremely 
fragile,  and  possess  no  middle  coat.  The  readiness  with 
which  they  give  way  is  thus  easily  explained. 

The  medical  jurist's  services  may  be  called  for  in  these 
cases  for  different  reasons.  The  individuals  who  are  affected 
with  pachymeningitis  are  either  alcoholic  subjects  or  are  in 
an  early  stage  of  insanity ;  in  either  case  the  disease  (alco- 
holism or  insanity)  may  have  hitherto  run  a  certain  part  of 
its  course  unnoticed,  and  pachymeningitis  may  have  de- 
veloped unperceived  even  by  the  patient  himself.  Suppose 
that  one  of  these  individuals  gives  way  to  a  violent  outburst 
of  anger,  or  that  he  gets  involved  in  some  common-place 
fight  or  scuffle ;  he  may  return  home  without  manifesting 
any  extraordinary  appearance  ;  but  the  next  day  he  may  be 
found  dead,  and  the  superintendent  of  police  will  remove 
his  body  to  the  Morgue. 

Meningeal  haemorrhage  does  not  take  place  suddenly ;  the 
little  vessels  which  give  way  do  not  permit  the  escape  of 
very  much  blood  at  a  time.  Life  is  compatible  with  the 
existence  of  haemorrhage,  as  long  as  the  compression  of  the 
brain  is  not  excessive ;  according  to  the  calibre  of  the 
ruptured  vessel,  life  may  be  prolonged  for  five,  six,  seven, [or 
eight  hours ;  and  even  recovery  is  possible. 


LESIONS  OF  THE  CIRCULATORY  SYSTEM.  157 

MM.  Motet  and  Vibert  met  with  the  following  case, 
which  is  somewhat  perplexing :  An  old  woman  was  the 
victim  of  a  burglar,  who,  receiving  unexpected  resistance 
from  her,  struck  her  over  the  head  with  his  jemmy.  The 
woman  became  unconscious,  and  suffered  in  various  ways 
from  the  injury,  but  recovered  after  a  time.  Meanwhile 
the  burglar  had  been  arrested ;  the  trial  was  nearly  at  an 
end,  when  the  woman  died  suddenly.  An  inquest  was  held, 
and  the  autopsy  revealed  the  presence  of  pachymeningitis 
and  considerable  haemorrhage  into  the  arachnoid.  This 
woman  was  neither  addicted  to  alcohol  nor  insane  ;  she  had 
not  exhibited  any  of  the  conditions  which  predispose  to 
pachymeningitis.  What  was  the  right  conclusion  to  come 
to  ?  Could  the  pachymeningitis  and  consecutive  haemor- 
rhage be  attributed  to  the  blow  inflicted  on  the  head  ? 
MM.  Motet  and  Vibert  did  not  venture  to  affirm  this ;  it  is 
probable  that  this  was  the  actual  course  of  events,  but  the 
medical  experts,  quite  properly,  did  not  feel  justified  in 
interpreting  the  facts  so  rigorously. 

C.  Capillary  Embolisms. — Capillary  embolisms  will  not 
detain  us  long ;  besides,  they  are  rarely  met  with  ;  septic 
emboli  are  the  commonest.  When  there  is  a  wound  on  any 
part  of  the  body,  especially  when  that  wound  is  gangrenous, 
as  in  bedsores  of  the  sacrum,  fatal  septic  emboli  may  be 
deposited  in  the  lungs.     Here  is  an  example: 

A  lunatic  died  in  the  St.  Evrard  Asylum.  He  complained 
before  death  of  pain  and  sense  of  suffocation.  The  patients 
around  him  accused  an  attendant  of  having  ill-treated  the 
deceased.  An  inquiry  was  held,  and  I  was  directed  to  make 
an  autopsy.  There  were  no  marks  of  blows  on  the  body, 
but  there  was  a  bedsore  over  the  sacrum,  and  there  were 
some  infarcts  in  the  lungs.  The  patient  had  died  of  septic 
embolism. 

I  ought  to  say,  Gentlemen,  that  since  the  introduction  of 
antiseptic  dressing  these  cases  have  become  much  more 
rare. 

I  cannot  pass  silently  over  a  certain  form  of  embolism 
which  has  been  called  '  embolism  of  fat,'  the  emboli  having 
been  formed  in  the  little  vessels. 


158  SUDDEN  DEATH. 


It  was  about  the  year  1880  that  Fournoy  and  von  Reck- 
linghausen beheved  that  they  could  trace  sudden  death 
following  fractures  to  these  fat  embolisms.  I  have  had  the 
opportunity  of  examining  cases  similar  to  those  in  which 
Recklinghausen  had  attributed  death  to  embolisms  of  fat. 
According  to  his  view,  these  emboli  were  formed  out  of 
the  medulla  of  the  fractured  bones,  which  penetrated  the 
veins  and  then  blocked  the  vessels.  For  my  part,  I  think 
that  these  fat  emboli  are  often  produced  by  the  putrefactive 
colonies  of  micro-organisms,  which  were  but  little  known 
fifteen  years  ago.  Since  microbiology  has  made  the  pro- 
gress with  which  3'ou  are  familiar,  and  since  the  colonies 
of  putrefaction  have  become  better  understood,  cases  of 
death  attributed  to  embolism  of  fat  have  become  extremely 
rare. 

D.  Local  Disturbances  of  the  Circulation. — I  come  now 
to  the  last  chapter  of  the  disorders  of  the  Circulatory 
System  which  may  lead  to  sudden  death. 

An  individual  may  die  from  anaemia  or  congestion  result- 
ing from  a  considerable  disturbance  of  the  general  or  local 
circulation.  You  know  that  these  two  circulations  are  to 
a  large  extent  independent  of  one  another.  I  will  name  to 
you  as  an  instance  a  blush,  the  erythema  of  modesty,  which 
follows  even  a  very  trifling  emotion.  Here  is  a  phenomenon 
of  congestion,  which,  if  it  shows  itself  in  a  very  marked 
degree,  may  entail  anaemia  of  some  other  part  of  the  system. 

In  cases  of  fatal  syncope  from  anaemia,  it  is  of  post- 
haemorrhagic  anaemia  that  we  should  think  first  of  all. 

I  must  mention  to  you  the  following  case  observed  by 
myself: 

A  pregnant  woman,  having  very  large  vulvo- vaginal 
varices,  was  returning  from  a  visit  to  a  midwife ;  a  formi- 
dable hemorrhage  came  on,  and  she  died  of  syncope.  The 
midwife  was  quite  innocent  of  causing  this  accident.  I  have 
many  times  had  to  make  an  autopsy  on  women  who  have 
died  of  post-partum  haemorrhage.  I  will  add  that  these 
women  were  often  those  who  had  just  committed  in- 
fanticide. 

A  man  covered  with  blood  and  giving  no  signs  of  life  was 


LESIONS  OF  THE  CIRCULATORY  SYSTEM.  159 

found  one  evening  on  a  seat  in  the  outer  boulevard.  The 
superintendent  of  police  thought  that  a  crime  had  been 
committed.  I  made  an  autopsy,  and  found  a  clot  reaching 
from  the  mouth  to  the  trachea ;  in  the  trachea  was  found  a 
fibrinous  clot,  like  those  which  form  in  the  heart.  I  was  able 
to  follow  up  this  clot,  and  proceeding  farther  and  farther,  I 
at  last  came  to  an  open  aneurysm  in  a  cavity  in  the  lung.* 

When  paracentesis  abdominis  is  performed,  at  the  moment 
that  the  blood  flows  again  into  the  little  abdominal  vessels 
which  the  pressure  of  the  contained  fluid  had  kept  closed, 
a  congestion  is  produced  here  which  may  entail  death  from 
cerebral  anaemia ;  even  a  moderate  degree  of  congestion 
may  suffice  to  bring  about  this  catastrophe. 

It  used  to  be  the  practice  when  an  individual  was  attacked 
with  copious  haemoptysis  to  apply  cupping-glasses  or  Junod's 
boot — you  know  that  apparatus  which  fits  closely  on  to  the 
leg  and  is  then  exhausted  of  air  ;  the  blood  is  drawn  with 
force  towards  the  lower  extremity.  In  America,  where  Junod's 
boot  is  still  frequently  employed,  though  almost  exclusively 
by  quacks,  fatal  syncope  is  frequent.  The  quantity  of  blood 
displaced  by  this  attraction  to  the  leg  can  scarcely  be  more 
than  if  pints,  yet  it  is  enough  to  cause  syncope. 

When  individuals  get  up  for  the  first  time  after  a  long 
illness,  fatal  syncope  may  take  place ;  it  is  therefore  neces- 
sary not  to  allow  convalescents  to  rise  hurriedly.  In  fact, 
a  sudden  congestion  takes  place  in  the  lower  limbs  when  we 
move  from  the  horizontal  to  the  upright  position. 

There  is  no  need  to  have  been  kept  to  bed  a  long  while  to 
experience  these  sensations.  We  have  all  sometim.es  felt 
giddy  or  dizzy  on  jumping  out  of  bed  in  the  morning,  due  to 
anaemia  of  the  brain  produced  by  sudden  congestion  of  the 
lower  limbs.  It  is  obvious  that  these  phenomena  will  be 
much  more  pronounced  in  convalescents  and  lying-in  women, 
and  may  even  be  sufficient  to  cause  fatal  syncope. 

Owing  to  the  doctrine  of  embolism  being  now  in  favour, 
this  syncope  will  nearly  always  be  attributed  thereto,  while 
in  reality  it  is  simply  due  to  cerebral  anaemia. 

*  It  is  perhaps  open  to  question  whether  death  in  this  case  was  not 
due  to  asph)xia  rather  than  to  syncope  from  anEemia.— Translator. 


i6o  SUDDEN  DEATH. 


You  will  not  find  anything  remaining  at  the  autopsy  which 
will  enable  you  to  conclude  that  syncope  has  occurred.  We 
possess  no  characteristic  sign  of  this  accident. 

In  connexion  with  the  subject  of  death  due  to  cerebral 
anaemia,  the  result  of  disturbance  of  the  general  circulation, 
it  is  appropriate  to  say  a  word  or  two  about  certain  forms 
of  congestion  which  may  likewise  entail  death.  I  refer  to 
those  attacks  of  congestion  to  which  the  subjects  of  alcoholic 
excess  are  liable.  Generally  these  persons  have  taken  food, 
and  eaten  heartily  while  intoxicated ;  they  go  to  bed,  then 
in  the  middle  of  the  night  they  turn  sick  and  vomit,  but 
cannot  effectually  expel  the  contents  of  their  stomach.  The 
food  that  they  have  eaten  enters  the  nasal  fossae,  the  trachea, 
and  bronchi,  and  they  die,  literally  drowned  in  their  own 
vomit.* 

*  Is  vomiting  in  these  cases  due  to  cerebral  congestion,  or  merely  to  irri- 
tation of  the  stomach  by  undigested  food  ? — Translator. 


LECTURE  III. 

SUDDEN    DEATH   IN    LESIONS    OF  THE   CEREBRO-SPINAL 
SYSTEM  AND  THE  MAJOR  NEUROSES. 

Gentlemen, — Certain  lesions  of  the  cerebro-spinal  system 
may  in  an  unexpected  way  give  rise  to  sudden  death  which 
appears  to  the  e3^e  of  the  law  to  be  of  a  suspicious  nature. 

I.  MENINGITIS. 

I  will  place  latent  meningitis,  acute  or  chronic,  first.  I 
shall  appear  to  you  to  be  guilty  of  an  enormous  medical  and 
scientific  barbarism.  You  have  been  brought  up  clinically 
in  the  idea  that  meningitis  reveals  itself  by  fever,  pain  in 
the  head,  vomiting,  muscular  spasm,  etc.  How,  then,  you 
will  say,  can  meningitis,  going  on  to  suppuration  of  the 
meninges,  develop  secretly,  without  attracting  any  attention, 
without  displaying  any  of  the  classical  symptoms  of  inflam- 
mation of  the  coverings  of  the  brain  ?  Well,  gentlemen, 
latent  meningitis  does  exist  .  .  .  and  its  existence  is  only 
discovered  post-mortem. 

Let  me  give  you  some  examples.  An  individual  felt  out 
of  sorts  all  at  once,  having  been  in  good  health  hitherto. 
He  went  to  a  druggist,  who  gave  him  two  pills ;  the  patient 
swallowed  the  pills  and  died.  The  druggist  was  accused  of 
having  poisoned  him.  Tardieu  made  the  autopsy,  and  found 
suppurative  meningitis,  with  a  layer  of  pus  of  appreciable 
thickness  spread  out  over  the  pia  mater. 

Ollivier,  of  Angers,  has  related  the  case  of  a  workman 
attacked  with  a  sudden  illness  while  he  was  at  his  work ;  he 

II 


1 62  SUDDEN  DEATH. 


went  to  bed  and  died  in  four  hours.    Suppurative  meningitis 
was  found  at  the  autopsy. 

Lastly,  M.  Vibert  made  an  autopsy  on  the  body  of  a 
prostitute  who  was  found  one  morning  in  a  bedroom  of  a 
hotel  with  the  death-rattle  in  her  throat.  She  was  brought 
to  the  hospital  and  died  there.  As  the  girl  had  come  to 
the  hotel  the  evening  before  in  the  company  of  a  man  who 
had  left  again  an  hour  afterwards,  the  idea  of  a  crime  natu- 
rally arose.  M.  Vibert  ascertained  at  the  autopsy  that  there 
was  a  sheet  of  pus  two-fifths  of  an  inch  thick  spread  over  the 
whole  extent  of  the  meshes  of  the  pia  mater. 

Each  of  these  patients  performed  all  the  normal  and 
physiological  acts  of  life  until  within  a  few  moments  of  their 
death ;  none  of  them  had  any  mental  disturbance,  pain, 
vomiting,  or  paralysis ;  their  meningitis  was  therefore  quite 
latent.     I  should  add  that  they  were  addicted  to  alcohol. 

Tubercular  meningitis  runs  its  course  under  the  same 
conditions  as  suppurative  meningitis.  The  results  of  in- 
quests on  such  cases  are  nearly  always  the  same ;  they  are 
generally  held  on  children  of  12  to  15  years  of  age.  These 
children  all  at  once  become  dull  and  sullen ;  they  have 
fits  of  ill-humour,  become  quarrelsome  and  sometimes  are 
beaten,  then  they  rapidly  die  in  the  course  of  12,  15,  or 
24  hours.  The  autopsy  reveals  the  presence  of  tubercular 
meningitis  that  must  have  lasted  8,  10,  or  sometimes 
20  days,  and  that  has  developed  without  any  of  the  earlier 
symptoms  or  signs. 

Chronic  meningitis,  so  well  described  by  MM.  Hanot  and 
Joffroy,  evidently  has  fewer  surprises  for  us.  The  two 
individuals  on  whom  they  made  autopsies  had  been  for  a 
longer  or  shorter  time  inmates  of  a  lunatic  asylum.  The 
suddenness  of  death  might  have  caused  an  attendant  to  be 
suspected,  and  it  is  such  suspicions  that  might  give  occasion 
for  an  inquest.  They  found  dropsy  of  the  fourth  ventricle, 
which  was  flattened  and  increased  in  breadth  to  double  its 
size. 

Cerehro -spinal  meningitis  is  happily  not  very  common  in 
France ;  it  prevailed  there  all  through  the  second  third 
of  this  century.     It  assumed  an  epidemic  character.     The 


LESIONS  OF  THE  CEREBROSPINAL  SYSTEM.  163 

epidemic  which  raged  three  or  four  years  ago  in  Cyprus 
was  very  severe.  Cerebro-spinal  meningitis  is  attended  by 
vomiting  and  paralysis,  and  death  takes  place  in  some  cases 
in  three  or  four  hours.  Often  the  disease  does  not  manifest 
itself  by  any  symptom  ;  it  runs  its  course  rapidly  and  secretly. 
When  there  is  an  epidemic  of  this  complaint  anywhere,  it 
serves  to  explain  any  sudden  death  that  may  happen,  and 
there  is  hardly  ever  any  need  for  an  inquest ;  but  when  such 
cases  occur  either  at  a  time  when  no  such  epidemic  is 
prevalent,  or  at  a  place  at  some  distance  from  the  seat  of 
the  epidemic,  they  cause  astonishment  and  baffle  explana- 
tion, and  the  officers  of  the  court  order  an  inquest. 

II.  ABSCESS  OF  THE  BRAIN. 

A  bscesses  of  the  brain  may  run  their  course  without  attract- 
ing the  attention  of  the  patient,  or  of  his  medical  attendant, 
or  of  those  about  him.  This  seems  all  the  more  extra- 
ordinary, because  I  am  not  speaking  here  of  those  miliary 
abscesses  the  size  of  which  does  not  exceed  that  of  a  pin's 
head,  but  of  those  abscesses  which  are  as  big  as  a  pigeon's 
egg,  or  even  a  hen's  egg.  These  abscesses  may  cause  death 
after  symptoms  which  only  last  a  few  hours. 

When  I  was  a  young  doctor  and  physician  to  the  Sainte- 
Barbe  College,  I  had  one  day  to  examine  a  young  servant 
of  the  institution  who  was  attacked  with  otitis.  I  sent  him 
into  the  hospital,  where  he  came  under  the  care  of  Bernutz. 
He  returned  in  a  fortnight,  apparently  completely  cured. 
On  the  evening  of  his  return,  to  celebrate  the  occasion,  he 
went  to  the  Vieux-Chene  ball,  where  he  drank  freely  and 
danced  all  night.  Next  morning,  after  his  return  to  Sainte- 
Barbe,  he  set  to  work  to  polish  the  floor  of  the  dormitory  as 
it  was  his  duty  to  do.  All  at  once  he  fell  down,  and  I  was 
summoned  to  see  him ;  as  he  had  become  unconscious,  I 
sent  him  back  to  the  hospital,  where  he  was  re-admitted, 
this  time  under  the  care  of  Gallard.  The  latter  noticed  that 
the  running  from  his  ear  had  nearly  ceased ;  the  patient 
gradually  recovered  his  senses,  but  died  suddenly  on  the 
following  day.  At  the  autopsy  an  abscess  the  size  of  a 
hen's  egg  was  discovered  in  the  temporo-sphenoidal  lobe. 


i64  SUDDEN  DEATH. 


This  abscess,  which  had  caused  death  in  a  very  sudden 
manner,  evidently  did  not  originate  merely  on  the  night  of 
the  ball,  but  must  have  developed  at  the  time  when  he  was 
under  Bernutz.  Thus,  this  man  had  for  a  fortnight  an 
abscess  in  process  of  formation  in  his  brain,  and  yet  he  was 
able  to  accomplish  all  the  normal  acts  of  existence. 

I  had  been  much  struck  by  this  case.  In  1866,  I  read 
before  the  Anatomical  Society  a  memoir  on  '  Caries  of  the 
Petrous  Portion  of  the  Temporal  Bone,''^"  and  I  found  in  the 
writings  of  Itard,  as  well  as  in  those  of  other  authors,  fifteen 
almost  identical  cases  of  abscess  of  the  brain  recorded.  These 
abscesses  are  usually  consecutive  to  caries  of  the  cranial 
bones,  but  very  rarely  to  syphilitic  lesions ;  these  abscesses 
are  very  frequent  as  a  result  of  caries  of  the  petrous  portion. 
Only  once  was  an  abscess  of  the  brain,  due  to  a  lesion  of 
the  bones,  provoked  by  a  blow.  This  case  was  reported 
by  Closmadeuc.  There  was  a  peripheral  haemorrhage. 
Toynbee  has  made  a  study  of  this  question  :  the  plate  of 
bone  which  separates  the  tympanum  from  the  meninges  is 
very  thin ;  it  is  sometimes  congenitally  absent.  On  the 
other  hand,  the  capillary  circulation  of  the  middle  ear  com- 
municates with  that  of  the  meninges.  It  is  intelligible, 
therefore,  how  easily  inflammation  may  be  propagated  from 
the  middle  ear  to  the  meninges.  It  is  less  easy  to  under- 
stand how  an  abscess  of  the  brain  comes  to  be  produced 
under  such  conditions,  because  abscesses  of  the  brain  are 
never  in  contact  with  the  carious  surface.  The  grey  matter 
is  intact ;  the  white  matter  alone  contains  the  abscess 
cavity.  It  would  seem  as  if  the  grey  matter  served  as  a 
barrier  to  the  abscess.  I  will  not  attempt  to  explain  to  you 
why  things  happen  thus  ;  I  only  beg  you  to  remember  this  : 
an  individual  who  has  lost  a  large  portion  of  one  cerebral 
hemisphere  may  live  for  a  certain  time  without  the  lesion 
being  made  manifest  by  any  disturbance  of  health  whatever. 

Is  this  contrary  to  physiology  ?     No. 

As  a  matter  of  fact,  long  before  the  occurrence  of  the  case 

which   I   have  just  related  to  you,   M.   Chauveau  injected 

different  substances  into  the  brains  of  living  sheep.      This 

*  Brouardel,  '  Carie  du  Rocher '  {Bzil/.  de  la  Soc.  Anat.,  li 


LESIONS  OF  THE  CEREBROSPINAL  SYSTEM.         165 

was  during  the  epoch  when  great  endeavours  were  being 
made  to  determine  the  question  of  cerebral  locahzation,  and 
M.  Chauveau  hoped  to  throw  some  hght  upon  the  question 
by  his  experiments.  He  began  by  injecting  water;  the 
sheep  was  somewhat  stunned  at  first,  but  soon  recovered 
and  went  on  grazing  in  the  field ;  then  suddenly,  on  the 
following  day,  it  sank  and  died.  After  water,  M,  Chauveau 
injected  other  substances,  including  chloride  of  zinc,  which 
transformed  that  part  of  the  brain  with  which  it  came  into 
contact  into  a  firm  magma.  The  results  were  always  the 
same,  but  the  experiments  have  not  been  pubHshed.  But 
I  remember  this  fact,  that  the  animals  could  live  with  a 
portion  of  their  brain  destroyed,  and  that  the  lesion  would 
not  be  revealed  by  any  external  sign.  Well,  Gentlemen,  it 
is  the  same  in  the  case  of  man. 

Some  time  ago  Itard,  a  celebrated  aurist  at  the  com- 
mencement of  this  century,  paid  great  attention  to  this 
subject.  He  collected  a  great  number  of  cases,  and  wrote 
that  Nature  was  very  provident,  inasmuch  as  the  cerebral 
abscess,  which  was  trying  to  work  its  way  towards  the 
exterior,  attacked  with  caries  the  very  thin  bony  lamella 
near  which  it  was  almost  always  situated,  in  order  to  give 
vent  to  the  pus.  This  condition  is  true  if  we  take  it  the 
reverse  way,  for  it  is  not  the  abscess,  but  the  caries  of  the 
petrous  portion,  which  is  the  initial  phenomenon. 

III.  CEREBRAL  TUMOURS. 

Cerebral  and  cerebellar  tumours  behave  almost  exactly  like 
abscesses  of  the  brain. 

We  are  less  surprised  to  find  them  at  the  autopsy,  for  we 
know  that  these  tumours  often  develop  without  giving  rise 
to  any  indications  of  their  presence.  Individuals  thus 
affected  may  have  attacks  of  vomiting,  which  are  put  down 
to  dyspepsia  ;  if  they  are  young  or  adolescent,  they  may 
have  hemichorea,  which  sometimes  suggests  the  idea  of  a 
cerebral  lesion.  Others  have  vertigo,  diabetes  insipidus,  or 
diabetes  mellitus.  None  of  these  symptoms  attract  much 
attention  ;  but  when  the  patient  suddenly  falls  down  either 


1 66  SUDDEN  DEATH. 


in  the  street  or  in  his  own  house,  the  more  or  less  singular 
circumstances  in  which  he  has  been  struck  down,  or  else  a 
wound  or  abrasion  occasioned  by  the  fall,  causes  the  law  to 
intervene. 

Here  is  an  example  :  A  dozen  years  ago  I  was  directed  to 
make  a  medico-legal  autopsy  in  a  case  with  the  following 
history :  It  was  the  commencement  of  a  strike.  Some 
paviors  who  had  a  disagreement  with  their  master  wished 
to  enter  his  office,  and  lay  their  complaints  before  him  before 
they  left  their  work.  Sharp  words  passed  between  them, 
a  dispute  followed,  and  the  master,  who  had  been  driven  to 
the  further  end  of  the  office,  tried  to  extricate  himself  by 
pushing  aside  two  or  three  of  the  workmen  who  were  stand- 
ing nearest  to  him.  One  of  these  men  suddenly  fell  dead. 
The  master  was  arrested  and  locked  up,  as  much  to  pre- 
serve him  from  the  fury  of  his  workmen  as  to  keep  him 
within  the  grasp  of  justice.  At  the  autopsy  I  found  in  the 
brain  of  the  deceased  workman  three  little  pediculated 
fibrous  tumours  on  the  anterior  wall  of  the  fourth  ventricle, 
the  largest  of  which  was  the  size  of  a  small  haricot  bean. 
This  man  had  been  for  some  time  in  imminent  danger  of 
sudden  death.  The  excitement  of  the  circulation  provoked 
by  the  quarrel  had  sufficed  to  bring  it  about.  His  body 
bore  no  trace  of  violence,  and  the  other  witnesses  of  the 
scene  declared  that  he  had  not  been  struck. 

These  examples  are  not  the  only  ones.  In  Germany, 
Maschka  looks  upon  alcoholic  excesses,  fatigue  of  all  kinds, 
and  dancing,  as  the  immediate  cause  of  death  during  the 
development  of  these  tumours. 

These  tumours  are  most  often  tubercle,  cancer,  or  fibroma  ; 
sometimes  hydatid  cysts  have  been  observed.  Lancisi 
reported*  a  case  a  long  time  ago  in  which  death  was  due 
to  the  presence  of  a  large  hydatid  on  the  surface  of  the 
brain,  fatal  either  by  rupture  or  by  compression  of  the 
brain. 

The  indifference  that  the  brain  sometimes  shows  to  the 
presence  of  tumours  is  confirmed  experimentally  by  its 
tolerance  of  foreign  bodies,  e.g.,  the  projectiles  of  fire- 
*  Lancisi.  '  De  subitaneis  Mortibus,'  libri  duo.     Romce,  1707. 


LESIONS  OF  THE  CEREBROSPINAL  SYSTEM.         167 

arms.  In  one  autopsy  we  found  a  revolver  bullet,  ^  inch 
in  diameter,  lodged  in  the  left  occipital  lobe,  where  it  had 
been  encysted  for  a  long  time,  and  a  second  similar  bullet, 
the  base  of  which  was  embedded  in  the  squamous  portion 
of  the  right  temporal  bone.  Both  were  the  results  of 
attempted  suicide  which  happened  several  years  previously. 
The  individual  at  last  put  an  end  to  his  life  by  hanging. 

Those  tumours  which  most  commonly  give  occasion  for 
medico-legal  investigations  are  located  in  the  bulb,  pons,  or 
crura  cerebri.  They  may  compress  the  veins  of  Galen,  and 
sometimes  reveal  their  existence  by  clouding  the  intellect, 
or  by  causing  vertigo  or  visual  trouble,  but  very  often 
nothing  occurs  to  make  their  presence  suspected.  I  shall 
only  mention  sudden  death  as  a  result  of  glosso-labio-laryngeal 
paralysis,  to  refresh  your  memory.  You  know  that  this 
affection  is  due  to  destruction  of  the  cells  of  the  nuclei 
where  the  motor  nerves  of  the  tongue,  lips,  and  larynx  have 
their  origin  in  the  bulb.  The  hypoglossal  is  the  first  to 
suffer,  then  the  facial,  then  the  pneumogastric. 

Sudden  death  is  also  one  of  the  anticipated  terminations 
of  acromegaly. 

IV.  LESIONS  OF  THE  SPINAL  CORD. 

I  come  now  to  lesions  of  the  spinal  cord.  I  shall  not 
say  much  about  medullary  haemorrhages,  which  are  ill 
understood.  As  far  as  my  experience  goes,  they  have  only 
given  rise  to  medico-legal  investigations  in  the  case  of 
women  either  during  pregnancy  or  after  confinement.  Potfs 
disease,  when  it  affects  the  spine  just  below  the  occiput,  may 
at  an  early  stage  lead  to  sudden  death.  By  the  name  '  Pott's 
disease '  is  understood  tubercle  of  the  vertebrae.  This  often 
only  manifests  itself  by  localized  pain  or  by  torticollis.  An 
abrupt  movement  or  violent  effort  may  cause  the  odontoid 
process  to  break  and  compress  the  spinal  cord.  There 
is  loss  of  consciousness,  and  more  or  less  rapid  death. 
Heurteaux,  of  Nantes,  has  narrated  a  case  of  sudden  death 
resulting  from  the  opening  of  an  abscess  due  to  Pott's 
disease  of  the  spine  just  below  the  occiput  into  the  spinal 
canal. 


i68  SUDDEN  DEATH. 


V.  EPILEPSY. 

The  question  of  sudden  death  in  the  course  of  an  attack 
of  epilepsy  is  of  great  interest.  When  even  an  experienced 
medical  jurist  publishes  a  treatise  or\  post-mortem  examina- 
tion in  relation  to  forensic  medicine,  he  finds  it  very  difficult 
to  assign  definite  and  pathognomonic  characters  to  death 
in  an  epileptic  fit.  In  the  treatises  which  you  have  in  your 
hands,  it  is  stated  that  death  is  due  either  to  rupture  of  the 
heart,  or  to  the  passage  of  food  from  the  stomach  into  the 
trachea  and  bronchi,  or  else  to  asphyxia  resulting  from  the 
position  occupied  by  the  patient  during  the  fit,  such  as  may 
cause  the  mouth  and  nose  to  be  pressed  into  the  pillow. 
In  the  first  case  it  is  clear  that  death  must  be  attributed 
to  a  lesion  of  the  heart ;  in  the  other  two,  to  a  merely 
mechanical  asphyxia.  There  is  nothing  therein  peculiar 
to  epilepsy. 

In  all  the  works  of  Charcot  or  of  M.  Grasset  at  the 
Salpetriere,  we  could  not  find  twenty  cases  of  death  from 
epilepsy.  And  yet  M.  Lesser  reports  17  cases  of  individuals 
dying  in  an  attack  of  epilepsia  gravior.  Looking  at  these 
cases  closely,  it  is  evident  that  he  includes  under  the  name 
*  epilepsy  '  all  sorts  of  convulsive  seizures — uraemia,  etc. 

What  are  the  signs  of  death  that  are  to  be  found  in  the 
true  epileptic  neurosis  ?  After  an  attack  we  find  that  the 
neck  and  shoulders  are  covered  with  spots  like  flea-bites, 
that  the  conjunctivas  are  injected,  that  the  tongue  is  bitten 
in  one  or  several  places,  and  that  the  bronchi  are  filled  with 
froth.  These  are  the  signs  that  we  shall  meet  with  in  the 
body  of  an  epileptic  who  has  died  in  a  fit.  We  have  no 
others  whereon  to  base  our  conclusions,  and  these  signs 
are  almost  the  same  as  in  death  by  strangulation  by  means 
of  a  somewhat  pliable  ligature,  such  as  a  handkerchief  or 
scarf,  which  does  not  leave  a  mark  on  the  skin  and  sub- 
cutaneous cellular  tissue. 

A  dozen  years  ago,  the  body  of  a  child  was  found  under 
a  heap  of  sacks  on  one  of  the  quays  of  Paris.  The  marks 
found  on  the  body  had  those  characters  which  I  have  just 
described  to   you.     There   was    no   very   distinct    mark  of 


LESIONS  OF  THE  CEREBROSPINAL  SYSTEM.         169 

strangulation  round  the  neck,  and  there  were  but  few 
ecchymoses  forming  punctate  lines.  The  case  was  about 
to  be  dismissed.  I  expressed  my  conviction  to  the  public 
prosecutor  that  that  child  had  been  strangled.  The  inquiry 
was  resumed,  and  the  truth  was  discovered.  The  child  wore 
a  scarf  round  its  neck,  with  the  ends  waving  behind.  His 
companions  had  pulled  the  ends  hard,  so  that  the  child  was 
strangled ;  and  then,  being  frightened  at  what  they  had 
done,  they  had  hidden  the  body  under  the  pile  of  sacks, 
in  the  midst  of  which  it  had  been  found. 

Many  diseases  also  may  produce  similar  lesions. 

The  law  interferes  in  the  case  of  death  in  the  course  of 
an  attack  of  epilepsy  on  account  of  attendant  circumstances 
which  may  make  the  death  look  suspicious.  I  know  of 
two  such  cases,  one  of  which  has  remained  deeply  graven 
on  my  memory  by  reason  of  the  tragic  consequences  it  had. 
A  tradesman,  33  years  of  age,  whose  business  was  beginning 
to  prosper,  accompanied  his  wife  to  the  station,  as  she  was 
going  on  a  journey.  On  returning  from  the  station  he  met 
a  girl,  whom  he  accosted  and  took  home  with  him.  After 
having  performed  a  certain  number  of  acts,  the  nature  of 
which  you  may  guess,  the  girl  went  to  the  water-closet,  but 
did  not  return.  The  man  became  uneasy,  rose  up,  and 
knocked  at  the  door,  but  obtained  no  answer ;  and  from 
sheer  weariness  he  went  to  fetch  the  porter,  who  broke 
open  the  door.  The  girl  had  died  in  the  water-closet,  and 
as  she  had  fallen  from  the  seat  she  had  injured  herself  in 
several  places  ;  among  other  injuries  she  had  a  scalp  wound. 
The  police  superintendent  took  the  matter  up,  and  an  inquest 
was  ordered.  This  girl  had  a  hard  chancre,  gonorrhoea,  and 
pus  in  the  bladder.  She  presented  also  punctate  ecchymosis 
of  the  conjunctivae  and  shoulders  ;  the  tongue  was  bitten, 
and  there  was  froth  in  the  bronchi.  My  conclusion  was 
that  this  young  woman  7night  have  died  from  an  epileptic 
fit.  The  superintendent  was  informed  from  other  sources 
that  she  was  subject  to  epileptic  convulsions. 

The  unfortunate  tradesman  acquired  syphilis  and  gonor- 
rhoea. The  scandal  induced  his  wife  to  petition  for  a 
divorce  ;  he  had  to  give   her  back  her  fortune.     Deprived 


I70  SUDDEN  DEATH. 


of  this  capital,  he  could  not  pa}'  his  debts ;  he  became 
bankrupt,  and  I  am  told  that  he  blew  his  brains  out  some 
years  afterwards. 

In  the  country  the  question  may  present  itself  under  a 
different  aspect.  Individuals  may  fall  into  the  fire  during 
epileptic  fits,  and  burn  themselves  more  or  less  severely. 
This  fact,  known  to  criminals,  has  sometimes  led  them  to 
throw  the  body  of  their  victim  into  the  fire,  or  to  set  the 
house  on  fire.  In  every  case  there  are  difficult  problems 
to  solve  in  medico-legal  inquiries  concerning  sudden  death 
in  the  course  of  an  epileptic  fit. 

I  can  relate  to  you  another  still  more  recent  case  : 

A  careless  young  fellow,  i6  or  17  years  of  age,  was  found 
dead  in  the  prison  van  which  was  carrying  him  from  the 
police-station  to  Mazas  prison.  The  municipal  guard  who  was 
in  the  van  said  that  the  individual  must  have  had  an  epileptic 
fit.  At  the  autopsy  I  only  found  a  little  froth  in  the  bronchi : 
there  was  no  punctate  ecchymosis  under  the  conjunctivae 
or  on  the  shoulders,  or  any  biting  of  the  tongue.  The 
inquiry  threw  no  light  on  the  epileptic  antecedents  of  the 
lad.  He  was  morally  abandoned,  and  had  no  relatives  ;  he 
had  run  away  from  the  situation  which  had  been  found  for 
him.  No  one  could  supply  any  definite  information.  I 
think  that  the  opinion  of  the  municipal  guard  was  correct, 
but  you  will  understand  that  I  could  not  base  my  conclu- 
sions on  the  diagnosis  of  a  Parisian  municipal  guard, 

I  do  not  know  any  more  difficult  question  for  the  medical 
jurist  to  solve,  if  he  is  not  already  aware  that  the  individual, 
whose  body  he  is  examining,  had  a  history  of  epilepsy. 

VI.  HYSTERIA. 

Sudden  death  in  the  course  of  a  hysterical  fit  is  much 
rarer  still  than  in  an  epileptic  attack.  The  cases  published 
by  M.  Grasset  of  Montpellier*  do  not  seem  to  me  to  be 
very  conclusive ;  they  refer  to  individuals  who  suffer  from 
albuminuria,  cerebral  tumours,  sclerosis,  etc.,  in  addition. 
It  seems  to  me  that  in  this  complicated  condition  it  is  not 

*  Grasset,  '  Maladies  du  Systeme  nerveux." 


LESIONS  OF  THE  CEREBROSPINAL  SYSTEM.         171 

the  hysteria,  but  the  organic  lesion,  to  which  sudden  death 
must  be  ascribed. 

Molliere  of  Lyons  is  the  only  author  who  has  published  a 
case  where  it  was  impossible  to  discover  any  cause  of  death 
whatever,  beyond  hysteria. 

VII.  INHIBITION.— SLIGHT  INJURIES. 

Insignificant  injuries,  even  the  slightest  blows,  may  bring 
about  sudden,  even  instantaneous,  death.  In  such  cases  as 
these  the  medical  expert  ma}^  be  extremely  perplexed. 
Before  proceeding  any  further,  allow  me  to  relate  to  you 
an  absolutely  typical  case  : 

Two  boys,  aged  12  and  14,  apprenticed  to  a  typographer, 
were  playing  in  the  workshop  after  luncheon  ;  they  rolled  on 
the  ground,  wrestling  together  and  throwing  one  another  over, 
but  were  laughing  all  the  time  and  had  no  quarrel  or  dispute. 
The  bell  rang  for  them  to  resume  work;  the  little  apprentice, 
who  was  at  that  moment  lying  uppermost,  rose  up  laughing, 
and  gave  the  other  a  slight  kick  in  the  epigastric  region, 
saying :  '  You  are  conquered ;  your  shoulders  have  touched 
the  ground.'  The  other  attempted  to  rise,  but  fell  back 
dead.  There  was  much  excitement  about  it  in  the  workshop. 
A  medico-legal  examination  was  made,  but  no  trace  of 
ecchymosis  could  be  found.  We  did  not  even  find  anything 
which  would  explain  the  fact  of  death,  unless  it  was  due  to 
a  small  hsemorrhagic  point  in  the  bulb  no  bigger  than  a  pin's 
point. 

This  case  is  the  type  of  absolutely  sudden  death  provoked 
by  a  blow  in  certain  regions  of  the  body,  although  the  blow 
may  not  have  been  violent. 

There  are  certain  regions  which  present  this  susceptibility; 
the  epigastrium  is  the  chief.  Lancisi,  Astley  Cooper,  and 
Maschka  have  reported  cases  of  sudden  death  following 
slight  violence  inflicted  here. 

[Sir  Astley  Cooper's  case  is  as  follows*  :  A  man  belong- 
ing to  the  India  House  was  attempting  to  lift  a  weight,  when 
another  came  up  and  jocosely  said :  'Here,  stand  on   one 

[*  Cooper,  '  Lectures  on  the  Principles  and  Practice  of  Surgery,'  Eighth 
Edition,  p.  9.] 


172  SUDDEN  DEATH. 


side,  and  let  an  abler  man  attempt  it ;'  and  at  the  same 
instant  gave  him  a  slight  blow  on  the  stomach,  when  the 
poor  fellow  dropped  down  and  expired.  His  bod}',  upon 
being  opened,  showed  no  marks  of  violence.] 

What  happens  in  such  a  case  ?  It  used  to  be  said  that 
death  took  place  from  syncope,  by  reflex  action  upon  the 
heart;  nowadays,  since  the  works  of  Brown-Sequard  have 
been  published,  we  call  it  death  b}'  *  inhibition.'  Instead  of 
a  reflex  movement,  there  is  produced,  on  the  contrary,  an 
arrest  of  one  of  the  functions  which  was  in  action  at  the 
time  the  violence  was  suffered.  What  are  the  functions 
which  are  always  in  operation  in  the  human  body  ?  They 
are  those  of  circulation  and  respiration  ;  and  these  are  the 
ones  which  are  arrested. 

It  has  been  observed  that  every  time  that  the  action  of 
the  heart  has  been  stopped  after  a  blow  on  the  epigastric 
region,  the  process  of  digestion  was  going  on.  I  have 
already  spoken  to  you  of  M.  Mirenowitch's  experiments  on 
frogs  ;  I  shall  not  recapitulate  them  ;  but  remember  that 
there  exists  an  intimate  relation  between  the  stomach  and 
the  heart,  by  means,  no  doubt,  of  filaments  of  the  pneumo- 
gastric. 

Next  to  the  epigastrium  must  be  placed  the  hypogastric 
region ;  a  kick  in  the  lower  part  of  the  abdomen  may  induce 
sudden  death. 

Records  of  sudden  death  after  violence,  even  though  this 
be  sHght,  applied  to  the  laryngeal  region,  are  rare.  Never- 
theless, such  cases  exist. 

You  remember  a  case  which  I  narrated  to  you,  while  we 
were  studying  the  '  moment  of  death,'  of  what  befell  a  certain 
priest  (p.  22),  who  was  dismissed  for  his  misconduct,  and 
accused  of  having  killed  his  mistress,  just  as  she  was  packing 
up  her  trunk.  The  priest  maintained  that  he  had  only 
clasped  his  quondam  mistress's  neck,  without  using  any 
force,  and  only  in  fun,  and  that  she  dropped  dead  immedi- 
ately. 

The  medical  jurists  of  the  time  did  not  venture  to  assert 
or  deny  the  possibility  of  such  a  fact. 

I  mentioned  to  you  also  that,  in  consequence  of  the  feeling 


LESIONS  OF  THE  CEREBROSPINAL  SYSTEM.         173 

excited  by  that  case,  an  officer  of  dragoons  said  that  one  of 
his  comrades  had  been  nearly  killed  in  the  same  manner. 

Since  then,  examples  have  multiplied.  Tardieu  has  re- 
corded the  case  of  an  old  woman  who  sold  some  snuff  to  a 
little  urchin.  While  he  was  waiting  for  his  screw  of  snuff, 
the  boy,  tickled'  by  the  sight  of  the  old  woman's  pomum 
Adami  moving  up  and  down  in  her  neck,  struck  her  a  blow 
on  the  larynx  as  if  he  were  trying  a  catch  a  butterfly ;  the 
woman  died  instantaneously. 

It  has  been  stated,  as  an  objection  to  the  medical  jurists 
who  believe  in  the  explanation  of  these  cases  by  inhibition, 
that  there  have  £een  many  others  in  which  individuals  have 
not  died  after  sustaining  injuries  of  considerable  violence 
over  the  region  of  the  larynx,  e.g.,  after  having  survived 
attempts  at  strangulation.  We  do  not  as  yet  know  the 
mechanism  of  such  processes,  but  we  know  that  they  occur; 
so  when  you  are  asked  in  a  court  of  law  if  it  is  possible  for  a 
person  to  die  when  placed  in  those  conditions  which  we 
have  just  been  examining,  you  should  reply :  '  It  is  possible.' 

Gentlemen,  there  are  also  other  parts  of  the  body  which 
possess  this  special  sensitiveness :  such  are  the  mouth  and 
nose. 

Volkmann  relates  that  he  had  to  operate  one  day  on  a 
hare-lip  in  a  child  a  year  old.  He  inserted  the  pins  ;  the 
child  became  blue  and  ceased  to  breathe  ;  he  removed  the 
pins,  and  the  child  returned  to  life.  Four  hours  afterwards 
Volkmann  wished  to  proceed  with  the  operation ;  this  time 
no  accident  occurred.  Volkmann  even  remained  for  some 
time  by  the  side  of  the  child  to  see  that  all  was  going  on 
well.  He  then  went  home,  but  was  sent  for  again  in  great 
haste ;  the  child  had  again  presented  the  same  grave 
symptoms  as  at  the  first  operation.  Volkmann  hastened 
back,  but  the  child  was  dead. 

The  experiments  of  Brown-Sequard  have  shown  that  the 
regions  over  which  the  branches  of  the  trigeminal  nerve  are 
distributed  have  the  same  susceptibility  as  the  epigastrium 
and  the  larynx.  It  has  also  been  thought  that  the  nape  of 
the  neck  might  be  included  among  these  '  privileged '  regions : 
there  is  only  one  case  on  record,  and  that  is  not  conclusive. 


174  SUDDEN  DEATH. 


Some  students  at  Aberdeen  thought  that  they  had  reason 
to  complain,  rightly  or  wrongly,  of  the  conduct  of  the 
University  porter,  and  resolved  to  play  him  a  trick  in  return. 
They  carried  him  off,  led  him  into  a  dark  room  in  which 
there  was  a  block  of  wood,  blindfolded  him,  and  told  him 
that  he  w^as  going  to  die.  The  porter  was  naturally  very 
much  agitated.  He  was  made  to  lay  his  head  on  the  block, 
then,  by  means  of  a  wet  cloth  twisted  into  a  lash,  one 
of  the  students  gave  him  a  blow  on  the  nape  of  the  neck. 
The  man  died  immediately,  to  the  stupefaction  of  the 
students. 

What  was  the  cause  of  death  ?  I  do  not  know  at  all. 
Was  it  the  blow  on  the  nape  of  the  neck  ?  It  is  possible. 
But  do  not  forget  that  the  larynx  rested  on  the  block,  and 
that  it  might  have  been  the  seat  of  a  shock  by  contrecotip,  or 
of  such  a  violent  injury  as  would  occasion  death. 

Certain  minor  operations  and  insignificant  wounds  some- 
times bring  about  rapid  or  sudden  death. 

In  Schmidt's  J ahrhilcher  I  find,  under  the  author's  name, 
the  following  case  : 

A  peasant  was  stung  by  a  bee ;  the  sting  was  followed  by 
syncope,  but  the  man  came  to  himself.  Two  years  after- 
wards he  was  again  stung  by  a  bee,  and  died.  This  man 
had  evidently  an  exceptional  susceptibility.* 

I  quote  this  case  to  you  because  there  was  no  question 
here  of  chloroform,  or  of  any  accident  complicating  surgical 
procedures.     The  same  applies  to  the  following  two  cases. 

Martineau  quotes  the  case  of  an  individual  in  whom  a 
hydatid  cyst  was  to  be  punctured  ;  the  trocar  did  not  enter 
the  cyst,  and  was  withdrawn.  Only  two  or  three  drops  of 
blood  escaped  ;  the  patient  suddenly  expired.  Were  any 
small  branches  of  the  pneumogastric  nerve  injured  ? 

Desnos  relates  a  different  case,  also  concerning  an  in- 
dividual suffering  from  a  hydatid  cyst.  Desnos  applied 
Vienna  paste  in  order  to  procure  the  formation  of  adhesions. 
Everything  went  on  well  at  first,  but  in  four  or  live  hours 
after  the  application  of  the  caustic,  the  person  died  sud- 

*  Inquests  are  reported  occasionally  on  cases  of  death  resulting  from 
the  sting  of  a  wasp,  often,  though  not  always,  about  the  mouth.- — Tr. 


LESIONS  OF  THE  CEREBROSPINAL  SYSTEM.         175 

denly,  although  no  lesion  of  the  heart  or  of  any  other  organ 
could  be  detected  post-mortem. 

Therefore,  under  the  influence  of  certain  extremely  super- 
ficial lesions  sudden  death  may  ensue.  Suppose,  now,  that 
chloroform  had  been  administered,  the  responsibility  of  the 
operator  would  be  called  in  question. 

Sudden  death  may  even  take  place  before  an  operation  is 
commenced.  A  patient  on  whom  lithotomy  was  about  to  be 
performed  died  at  the  very  moment  at  which  the  surgeon 
was  introducing  the  sound  into  the  urethra.  There  was  no 
autopsy,  and  I  will  do  no  more  than  mention  the  case. 

I  can,  however,  relate  a  more  recent  one  of  the  same  sort : 

M.  Legroux  sought  the  aid  of  M.  Routier  in  applying  a 
splint  to  one  of  his  patients  who  had  broken  the  neck  of 
her  femur.  While  these  gentlemen  were  making  their  pre- 
parations in  an  adjoining  room  the  woman  died.  Suppose 
this  death  had  happened  in  the  course  of  an  operation  after 
the  administration  of  chloroform  or  cocaine,  I  need  not  tell 
you  what  the  consequences  would  be.  You  ought  always 
to  keep  these  cases  in  your  mind,  especially  if  you  happen 
to  be  called  upon  as  experts  to  sit  in  judgment  upon  your 
fellow-practitioners. 

The  presence  of  foreign  bodies  in  the  pharynx,  larynx, 
and  oesophagus  produces  a  more  or  less  rapid  death  ;  but 
these  cases  do  not  belong  to  the  special  chapter  of  forensic 
medicine  upon  which  I  am  now  discoursing  to  you. 

Gentlemen,  you  can  see  that  in  a  large  number  of  cases 
medico-legal  investigation  will  only  lead  to  very  inconclusive 
results  if  you  do  not  know  the  manner  in  which  the  fatal 
accident  has  happened,  and  if  you  have  not  been  made 
acquainted  with  all  the  details.  Suppose  the  case  is  one  of 
a  child's  death  from  convulsions,  your  scalpel  will  give  you 
no  scientific  proof  of  the  pathogeny  of  death  in  this  case,  or 
in  a  great  many  others. 

I  advise  you  also  to  reply  very  clearly  and  without  hesi- 
tation to  the  questions  which  the  judge  asks  you,  and  to 
say,  *  I  can  find  no  lesion  which  can  explain  death.'  You 
will,  of  course,  state  all  the  morbid  phenomena  that  you 
have  found  in  the  heart,  the  brain,  the  liver,  the  kidneys,  and 


176  SUDDEN  DEATH. 


every  other  organ  ;  but  you  should  add  that  other  persons 
ma}^  have  lesions  quite  as  serious  without  death  taking 
place  ;  you  should  say  that  you  are  obliged  to  confess  that 
it  is  impossible  for  you  to  say  what  is  the  actual  cause  of 
death. 

It  is  no  humiliation  for  a  medical  jurist  to  acknowledge, 
after  making  the  most  conscientious  research,  that  he  does 
not  know ;  but  it  would  be  humiliating  for  him  to  recognize 
that  he  has  made  a  mistake. 


LECTURE  IV. 

SUDDEN  DEATH  DUE  TO  LESIONS  OF  THE  RESPIEATORY 

SYSTEM. 

Gentlemen, — We  shall  devote  our  attention  successively 
to  lesions  of  the  larynx,  trachea,  bronchi,  lungs,  and  pleurae. 

I.  LESIONS  OF  THE  LARYNX,  TRACHEA,  AND  BRONCHL 

A.  Lesions  of  the  Larynx. — I  described  to  you  those 
lesions  of  the  larynx  which  may  cause  sudden  death  when  I 
spoke  to  you  of  the  inhibitory  phenomena  which  follow 
blows  inflicted  on  the  laryngeal  region  ;  but  I  am  anxious  to 
tell  you  first  of  all,  and  I  entreat  you  to  keep  it  in  mind,  that 
sudden  death  is  caused  much  more  often  by  superficial  than 
by  deep  lesions  of  the  larynx.  Tubercular  or  syphilitic 
ulceration  of  the  mucous  membrane  of  the  larynx  may  cer- 
tainly give  rise  to  oedema  of  the  glottis  and  asphyxia ;  but 
this  oedema  is  foreseen  :  the  quality  of  the  patient's  voice  has 
been  altered  for  a  long  while,  he  coughs,  expectorates  abun- 
dantly, and  has  become  aphonic.  There  is  no  ground  for 
surprise. 

We  are,  however,  baffled  by  such  a  case  as  this :  A  man, 
42  years  of  age,  wished  to  catch  an  omnibus.  He  ran  about 
ten  paces,  jumped  on  to  the  platform,  and,  at  the  very 
moment  he  was  entering  the  vehicle,  fell  down  dead.  At 
the  autopsy,  two  very  small  polypi,  as  large  as  peas,  were 
found  close  to  the  ventricle  of  the  larynx,  and  it  was  then 
ascertained  that  this  man  had  come  up  from  the  provinces 
some  days  before  to  undergo  an  operation  for  the  removal 

12 


178  SUDDEN  DEATH. 


of  these  growths.  He  had  had  no  attack  of  spasm  or  of 
laryngitis  before  his  death. 

In  adults,  sudden  death  may  be  due  to  the  presence  of  a 
polypus  in  the  larynx.  In  children  it  may  occur  in  the 
course  of  laryngismus  stridulus,  or  at  the  moment  of  remov- 
ing the  cannula  after  the  operation  of  tracheotomy.  Some 
children  do  actually  die  in  these  last  conditions.  In  others 
it  may  be  necessary  to  replace  the  cannula,  in  order  to 
obviate  the  laryngeal  spasm  which  threatens  to  carry  them 
off,  and  who  will  be  saved  by  this  means. 

What  are  the  causes  of  these  spasms  ?  Authors  differ. 
Some  have  found  little  vegetations  around  the  cicatrices, 
which  they  say  cause  the  spasms  which  compel  further 
operative  interference.  Others  state  that  they  have  never 
found  anything  of  the  kind,  and  that  death  takes  place  un- 
expectedly. I  will  not  say  which  is  true.  I  merely  advise 
you  to  remember  the  dangers  which  a  child  may  incur  upon 
removal  of  the  tracheotomy  tube. 

B.  Lesions  of  the  Trachea. — I  must  draw  your  atten- 
tion particularly  to  fatal  asphyxia  resulting  from  the  intro- 
duction into  the  trachea  of  food,  the  contents  of  a  pulmonary 
cavity,  or  of  a  lumbricus  which  has  contrived  to  ascend  into 
the  pharynx  and  enter  the  glottis. 

The  most  common  cases  are  evidently  those  in  which  food 
coming  from  the  stomach  has  been  introduced  into  the 
trachea.  The  following  case  is  borrowed  from  Laennec  : 
'  Professor  Corvisart,  wishing  to  pay  surprise  visits  to  a 
certain  department  of  the  Clinical  Hospital,  went  there  one 
evening  at  an  unusual  hour.  He  entered  the  porter's  lodge, 
and  found  this  individual  digesting  his  dinner,  with  which 
he  had  taken  too  much  to  drink.  The  man  was  surprised, 
and  felt  sick,  but  made  a  violent  effort  to  restrain  vomiting. 
He  fell  to  the  ground  and  expired.  When  the  body  was 
opened,  the  bronchi,  trachea,  and  larynx  were  found  full  of 
half-digested  food.'* 

Gentlemen,  whether  or  not  an  individual  has  made  such 
a  bacchic  repast  is  of  little  consequence.  He  feels  that  he 
must  be  sick,  though  he  wishes  not  to  vomit  because  he  is 
*  Laennec,  'Auscultation  mediate,'  3rd  edition,  tome  i.,  p.  259. 


LESIONS  OF  THE  RESPIRATORY  SYSTEM.  179 

in  the  presence  of  his  superior,  or  of  some  one  before  whom 
he  would  be  ashamed  to  do  so.  He  strives  by  a  violent 
effort  not  to  expel  the  food  which  is  thrown  up  his  oesophagus 
into  his  throat.  The  chymous  mass  enters  the  trachea,  and 
he  dies,  asphyxiated. 

In  order  to  understand  the  readiness  and  the  force  with 
which  foreign  bodies  may  enter  the  trachea  and  bronchi,  I 
will  mention  to  you  the  case  of  a  sewerman,  who  fell  in  the 
sewer  of  the  Rue  Rochechouart  with  his  face  in  the  trench 
of  the  sewer,  and  whose  trachea  M.  Descourt  found  to  be 
stuffed  with  sewage  sediment,  as  if  rammed  in  by  a  ramrod, 
and  in  the  midst  of  this  mass  was  a  pebble  as  large  as  a 
haricot  bean,  which  had  been  made  to  enter  there  by  a 
strong  effort  of  inspiration.  Further  evidence  is  afforded  by 
those  new-born  infants  who  are  thrown  into  privies  and  fall 
into  semi-solid  fsecal  matter;  they  make  efforts  at  inspiration, 
and  thus  introduce  this  matter  to  the  finest  extremities  of 
the  bronchial  ramifications.  When  a  section  is  made  of 
their  lungs  at  the  autopsy,  and  pressure  is  applied,  little 
threads  like  pieces  of  vermicelli  are  squeezed  out,  the  excre- 
mentitious  nature  of  which  it  is  easy  to  recognize. 

C.  Lesions  of  the  Thyroid  Body.  —  The  trachea  and 
bronchi  may  be  compressed  from  without  by  a  morbid  con- 
dition, which  sometimes  occasions  sudden  death.  This 
disease  is  hypertrophy  of  the  thyroid  gland.  It  is  true 
that,  in  cases  of  very  large  suffocating  goitres,  attention  is 
aroused,  and  the  accidents  which  may  happen  are  foreseen. 
But  goitres  may  lead  to  sudden  death  although  they  are 
quite  small,  and  do  not  give  rise  to  stridulous  breathing  or 
to  attacks  of  dyspnoea  ;  in  women,  whether  pregnant  or  not, 
haemorrhages  may  take  place  in  cysts  of  the  thyroid  body, 
and  prove  rapidly  fatal. 

D.  Lesions  of  the  Mediastinum. — Tuberculosis  of  the 
bronchial  glands  may  also  bring  about  sudden  death. 

Cases  may  present  themselves  in  several  forms  : 
I.  The  existence  of  tuberculous  glands  around  the  bronchi 
is  not  easy  to  recognize ;  sudden  death  happens  more  fre- 
quently in  these  cases   than    in   others.     Remember  what 
you    see   in    a   strumous    child  whose    cervical   glands,  for 


i8o  SUDDEN  DEATH. 


example,  are  swollen :  it  seems  to  you  at  first  that  these 
glands  are  enlarged ;  they  are  really  small.  It  is  the  sur- 
rounding tissue  which  is  oedematous  and  swollen,  and  its 
congestion  gives  the  gland  its  enormous  appearance.  It  is 
the  same  with  the  bronchial  glands.  The  nodular  mass 
compresses  the  trachea,  and  if  the  process  takes  place  in 
youths  or  in  children,  whose  trachea  and  bronchi  are  very 
soft,  the  pressure  may  be  so  great  that  death  occurs  in  an 
attack  of  suffocation  in  the  course  of  two  or  three  hours. 
It  is  very  difficult  in  such  a  case  to  make  a  precise  diagnosis. 
Auscultation  reveals  nothing  of  importance,  and  percussion 
alone  can  give  you  a  clue. 

2.  In  the  second  period,  when  there  have  been  repeated 
attacks  of  inflammation  of  the  peri-glandular  cellular  tissue, 
it  is  no  longer  soft  and  yielding,  but  becomes  hard  and 
resistant ;  it  continues  to  contract,  and  thus  constricts  the 
trachea  and  bronchi.  The  bronchial  glands  themselves  are 
hard  and  degenerated,  sometimes  containing  calcareous  de- 
posits. They  may  be  expelled  after  having  perforated  the 
trachea.  Fritz,  one  of  my  fellow-assistants  in  the  hospital, 
had  to  perform  tracheotomy  one  day,  on  an  emergency, 
upon  the  daughter  of  the  director  of  the  hospital  to 
which  he  was  attached ;  this  little  girl  was  stifled  and  very 
nearly  asphyxiated,  when  Fritz  withdrew  from  the  trachea 
a  calcareous  body  which  was  nothing  but  a  bronchial 
gland. 

Under  the  influence  of  this  compression  bronchial  spasm 
is  produced,  followed  by  fatal  syncope.  An  autopsy  will 
immediately  disclose  the  cause  of  death  in  this  case. 

Rilliet  and  Barthez  have  stated  in  their  book  that  the 
large  bloodvessels  may  be  opened  by  the  ulceration  into 
them  of  bronchial  glands  which  have  become  hard  and 
cretaceous.  This  may  possibly  occur,  but  at  any  rate  it  is 
very  rare,  and  I  have  not  seen  it  mentioned  by  anyone 
except  these  two  authors. 

Sudden  death  has  been  observed  in  cancer  of  the  medias- 
tinum. I  have  only  met  with  one  such  case,  and  it  gave  rise 
to  medico-legal  inquiry. 

An    attendant    at   the    Necker    Hospital  was    accused  of 


LESIONS  OF  THE  RESPIRATORY  SYSTEM.  i8i 

having  strangled  a  patient  who  was  restless  in  his  bed. 
The  autopsy  disclosed  the  fact  that  this  individual,  on 
whose  body  no  trace  whatever  of  violence  could  be  de- 
tected, had  an  enormous  mediastinal  cancer  three  inches  in 
diameter ;  this  cancer  compressed  the  trachea  so  as  to 
completely  flatten  it. 

With  regard  to  this,  allow  me,  by  way  of  parenthesis, 
to  put  you  on  your  guard  against  accusations  against 
hospital  attendants,  which  are  nearly  always  made  at 
random.  I  remember  a  case  which  occurred  in  the  St. 
Anne  Asylum.  A  lunatic,  who  was  somewhat  less  mad 
than  the  rest,  was  employed  there  in  helping  to  keep  the 
books  of  the  establishment.  One  day,  while  turning  over 
the  leaves  of  the  register,  he  came  across  the  name  of  a 
deceased  patient  with  this  note  appended  :  '  Internal 
strangulation.' 

The  madman  plied  his  imagination,  and  persuaded  him- 
self that  this  patient  had  been  strangled  by  one  of  the 
house-physicians.  He  made  formal  accusation  to  the  police, 
so  that  the  law  took  the  matter  up ;  exhumation  was 
ordered,  and  at  the  autopsy  intestinal  strangulation  was 
found,  which  had  caused  death. 

Gentlemen,  we  may  smile  when  we  read  of  such  cases : 
they  are  very  difficult  to  clear  up,  and  they  cause  the 
medical  expert  the  greatest  annoyance. 

II.  LESIONS  OF  THE  LUNGS. 

A.  Pulmonary  Congestion. — Pure,  ideal  pulmonary  con- 
gestion, without  any  primary  or  concomitant  disease,  is  very 
exceptional.  We  shall  have  to  speak  of  sunstroke  and  heat- 
stroke in  this  connexion. 

I  think  that  the  cases  of  idiopathic  pulmonary  congestion 
reported  by  different  authors  as  having  caused  sudden  death 
should  be  accepted  with  caution.  Hourmann  relates  that  a 
young  man  went  to  a  ball  after  partaking  of  a  heavy  dinntr, 
and  suddenly  fell  down  dead.  He  adds  that  the  heart  was 
very  large. 

Dr.  Fortassin,  who  had  advanced  cardiac  disease,  retired 


1 82  SUDDEN  DEATH. 


to  bed  ;  in  the  night  ratthng  was  heard  in  his  throat ;  his 
friends  ran  to  his  side,  but  he  died.  At  the  autopsy  his 
lungs  were  found  to  be  hke  two  bags  of  blood  ;  the  right 
lung  was  extensively  lacerated,  and  the  pleural  cavity  was 
full  of  blood. 

This  case  is  not  one  of  idiopathic  pulmonary  congestion, 
but  of  an  accidental  complication  of  heart  disease,  which 
seems  to  have  caused  death. 

The  same  remark  applies  to  the  following  case,  related  by 
Ollivier  of  Angers  : 

A  man  was  in  arrears  with  his  rent  ;  in  an  interview  with 
his  landlord  a  somewhat  violent  dispute  took  place,  and  the 
man  died  suddenly.  At  the  autopsy  it  was  found  that  he 
had  adherent  pericardium. 

M.  Verneuil  has  related  several  cases  of  death  from  pul- 
monary congestion  in  the  course  of  erysipelas  ;  Devilliers, 
in  the  puerperal  state.  Houde  wrote  his  inaugural  thesis 
on  the  frequency  of  pulmonary  congestion  in  articular 
rheumatism.  These  are,  in  my  opinion,  examples  of 
secondary  pulmonary  congestion. 

I  believe  that  pulmonary  congestion  sufficiently  intense 
to  induce  sudden  death,  without  any  concomitant  disease, 
is  extremely  rare,  and  that  an  autopsy  will  always  reveal 
the  disease  which  has  determined  the  pulmonary  congestion. 
On  one  occasion,  at  the  Morgue,  I  came  to  the  conclusion 
that  death  was  due  to  pulmonary  congestion.  Both  lungs 
were  really  gorged  with  blood,  but  the  bronchi  were  the  seat 
of  considerable  dilatation — being  large  enough  to  hold 
pigeons'  eggs  placed  in  a  row  ;  between  the  dilated 
bronchi  the  pulmonary  tissue  was  in  the  condition  of 
chronic  pneumonia. 

When  there  is  a  less  extensive  disease  of  the  lungs, 
there  may  be  a  violent  congestion  around  this  lesion — 
quite  out  of  proportion  to  the  importance  of  the  lesion 
itself;  still,  the  primary  disease  exists. 

We  have  nowadays  quite  given  up  using  the  phrase 
'  fluxion  to  the  chest '  ;  we  use  the  term  '  pneumonia ' 
instead.  '  Fluxion  '  has  disappeared  from  our  vocabulary, 
and,  in  fact,  nothing  can  be  seen   of  it  post-mortem ;  but. 


LESIONS  OF  THE  RESPIRATORY  SYSTEM.  183 

nevertheless,  it  is  an  accompaniment  of  some  diseases,  and 
constitutes  a  source  of  danger  to  life. 

As  a  consequence  of  tuberculosis  or  of  renal  or  cardiac 
disease,  pulmonary  congestion  may  occur,  and  may  bring 
about  sudden  death,  but  it  is  not  idiopathic. 

B.  Pneumonia. — I  come  now  to  sudden  death  in 
pneumonia. 

Gentlemen,  when  we  hear  for  the  first  time  of  sudden 
death  in  a  case  of  pneumonia,  we  feel  as  much  astonishment 
as  when  we  are  told  of  sudden  death  in  abscess  of  the  brain  ; 
and  yet  pneumonia  may,  under  certain  circumstances,  run 
its  course  in  a  latent  manner,  and  only  be  recognized  post- 
mortem. Hourmann  and  Dechambre  were  the  first  to  give 
a  systematic  account  of  sudden  death  in  pneumonia,  while 
they  were  house-physicians  at  the  Salpetriere.  At  that 
time  science  was  dominated  by  the  views  of  Morgagni  on 
morbid  anatomy  ;  everyone  endeavoured  to  classify,  define, 
and  catalogue  diseases  ;  sudden  death  in  pneumonia  was  put 
down  to  cerebral  congestion.  Hourmann  and  Dechambre 
noticed  that  female  inmates  of  the  Salpetriere  would  some- 
times die  suddenly  under  singular  conditions ;  for  instance, 
they  might  have  taken  their  breakfast  and  be  walking  in  the 
garden  or  sitting  on  a  bench  talking  to  their  companions, 
and  all  at  once  fall  down  dead.  Post-mortem,  these  gentle- 
men found  extensive  pneumonia  that  must  have  existed  for 
several  days,  and  yet  had  given  rise  to  no  symptoms.  We 
understand  these  cases  better  now.  Charcot  has  described 
them  well,  and  has  proved  that  not  only  is  there  no  rise  of 
temperature  in  such  patients,  but  that  the  temperature  is 
even  subnormal. 

I  do  not  wish  to  discuss  the  question  of  the  absence  of 
fever  and  of  other  symptoms ;  I  am  standing  on  medico- 
legal ground.  You  will  sometimes  meet  with  cases  of 
pneumonia — even  suppurative  pneumonia — that  have  de- 
veloped in  an  entirely  latent  manner,  in  old  people,  in 
alcoholic  subjects,  or  in  those  persons  who  are  midway 
between  health  and  disease — pregnant  women,  for  example 
(Ollivier  d'Angers).  The  circumstances  which  call  for 
judicial  inquiry  are  always  the  same  :  an  individual,  who  did 


SUDDEN  DEATH. 


not  seem  ill  previously,  dies  suddenly,  under  suspicious, 
perhaps  tragic,  conditions.     Here  is  an  example  : 

A  woman,  66  years  of  age,  was  found  in  her  room  with 
gurgling  in  her  throat ;  and  a  plug  of  linen  lay  between  her 
lips  :  she  died  without  being  able  to  give  any  explanation  of 
her  condition,  and  her  body  was  removed  to  the  Morgue 
for  the  purpose  of  an  autopsy  being  performed  upon  it. 

Quite  a  romance  had  been  constructed  on  the  incidents 
of  this  case.  The  porter  remembered  that  a  man  had 
accompanied  this  woman  to  her  room,  and  had  left  the 
house  shortly  after ;  he  was  able  to  describe  this  man,  who 
was  identified  and  arrested. 

This  woman  had  a  perforation  of  the  arch  of  the  palate ; 
upon  investigation,  it  was  proved  that  she  was  accustomed 
to  plug  this  aperture  with  a  linen  tampon.  The  autopsy 
demonstrated  that  she  was  suffering  from  pneumonia,  and 
that  the  tampon  had  become  displaced  and  wedged  be- 
tween her  teeth,  either  in  her  delirium  or  in  the  agony  of 
death. 

Accidents  such  as  that  which  complicated  this  case  call 
forth  the  interference  of  the  officers  of  the  court. 

Some  years  ago  there  was  brought  to  the  Morgue  the  body 
of  a  hump-back,  which  had  been  found  in  the  Seine  and  had 
not  been  identified.  The  hair  was  as  black  as  possible,  and 
none  of  the  teeth  were  wanting,  though  they  were  somewhat 
worn  down ;  these  two  facts  made  us  think  that  the 
individual  was  about  60  years  of  age.  At  the  autopsy  we 
found  pneumonia  of  the  apex.  This  individual,  whose  hair 
and  teeth  were  so  well  preserved,  was  an  alcoholic  subject, 
who  had  thrown  himself  into  the  Seine  in  an  attack  of 
delirium  in  the  course  of  pneumonia. 

It  was  found  on  making  inquiry  that  he  was  80  years  of 
age.  I  quote  this  case  incidentally  to  impress  on  you  that 
we  have  no  certain  criterion  of  the  age  of  any  individual 
whose  case  we  may  have  to  examine.  Say  simply  that  the 
individual  appeared  to  be  of  such  or  such  an  age. 

C.  Capillary  Bronchitis. — Capillary  bronchitis  may  cause 
death  under  somewhat  different  conditions.  I  shall  not 
speak  here  of  the  form  which  is  met  with  in  childhood,  but 


LESIONS  OF  THE  RESPIRATORY  SYSTEM.  185 

shall  come  to  that  later  on  ;  I  shall  only  deal  with  it  now  in 
so  far  as  it  attacks  youths,  adults,  and  old  people. 

The  term  '  suffocating  catarrh  '  is  a  very  appropriate  one 
for  this  condition ;  it  admirably  characterizes  the  patho- 
logical condition  to  which  it  is  applied.  It  supervenes  in 
old  people  from  exposure  to  cold.  In  most  cases  it  does 
not  give  rise  to  any  medico-legal  investigation  ;  in  others  an 
inquest  is  called  for.  Under  certain  conditions  adults  may 
be  affected.  During  the  siege  of  Paris,  I  lost  150  soldiers 
or  '  Gardes-Mobiles '  at  the  Javel  ambulance  station,  from 
capillary  bronchitis.  It  was  intensely  cold  in  December, 
and  you  know  that  many  of  these  unfortunate  men  had 
their  feet  frozen,  with  formation  of  eschars ;  they  were  also 
insufficiently  fed.  These  young  soldiers  guarded  the 
trenches  at  night.  They  were  cold  and  were  overcome  with 
dizziness,  so  that  they  had  the  appearance  of  being  drunk. 
They  had  to  be  led  to  the  ambulance ;  they  could  not  even 
undress,  but  fell  all  of  a  heap  on  their  beds  and  went  to 
sleep.  At  the  end  of  five  or  six  hours  they  died,  with  their 
mouths  full  of  froth,  the  product  of  bronchial  over-secretion. 

M.  Ranvier,  who  held  an  appointment  at  the  Val-de- 
Grace  Hospital,  at  the  same  time  met  with  precisely  similar 
cases. 

According  to  the  information  which  we  managed  to 
collect,  these  men  had  been  attacked  first  with  aphonia  and 
bronchitis,  and  they  suffered  from  general  exhaustion.  On 
post-mortem  examination,  we  always  found  the  bronchial 
tubes  filled  with  froth  and  the  lungs  scattered  with  black 
apoplectic  foci,  varying  in  size  from  that  of  a  hazel-nut  to 
that  of  a  walnut.  These  phenomena,  which  were  met  with 
in  soldiers  who  were  merely  suffering  from  a  catarrh,  were 
repeated  in  an  identical  form  in  January  in  some  of  their 
comrades,  when  an  epidemic  of  measles  was  raging  in  their 
ranks. 

It  is  as  well  that  you  should  know  of  these  cases ;  in 
winter  we  often  read  in  the  newspapers,  when  the  weather 
is  very  cold  in  Alsace-Lorraine,  the  north  of  France,  or  else- 
where, that  an  individual — a  carrier,  for  example — has  been 
found  dead  on  the  roadside.     You  may  be  asked  for  your 


1 86  SUDDEN  DEATH. 


opinion  as  a  medical  expert.  Remember  that  the  presence 
of  froth  in  the  bronchi,  subpleural  ecchymoses,  and  pulmo- 
nary apoplexies  may  be  the  effect  of  intense  cold,  and  so 
the  hypothesis  of  crime  may  be  dissipated.  Children  used 
to  be  told,  and  quite  rightly,  not  to  drink  cold  water  while 
in  a  perspiration.  I  saw,  at  Ste.  Barbe,  two  young  people 
die  in  an  identical  manner  after  drinking  water  drawn  from 
the  pump  when  they  had  been  playing  at  prisoner's  base. 
In  these  cases  the  cold  did  not  act  upon  the  external  surface 
of  the  body,  but  by  reflex  action  on  the  lungs  by  means  of 
the  pneumogastric.  In  such  cases  as  these  you  will  have  to 
decide  as  to  the  responsibility  of  the  principals — head- 
masters of  schools  or  directors  of  institutions  ;  there  is  no 
fault  that  they  can  be  reproached  with,  except  that  of 
allowing  their  pupils  to  have  access  to  a  tap  of  water. 

Capillary  bronchitis  offers  a  further  point  of  interest.  It 
may  happen  as  a  result  of  an  accident  which  is  called  '  night- 
man's asphyxia.' 

I  have  notes  of  three  cases  which  happened  in  two  acci- 
dents of  this  kind.  You  know.  Gentlemen,  what  is  meant 
by  '  nightman's  asphyxia.'  A  workman  goes  down  into  a 
cesspool  that  has  previously  been  opened  ;  he  gives  a  few 
blows  with  his  pickaxe  and  suddenly  falls  down.  Remember 
that  the  workmen  are  supposed  to  wear  a  belt  to  which  a 
rope  is  fastened  ;  but  workmen  will  not  comply  with  regula- 
tions, even  those  which  are  expressly  framed  to  ensure  their 
safety  while  engaged  in  their  work. 

When  a  cesspool  is  emptied,  it  is  generally  deemed  suffi- 
cient to  empty  it  partially,  i.e.,  to  remove  the  liquid  and 
semi-liquid  matter.  After  this  process  has  been  repeated 
several  times,  the  faecal  matters  form  a  thick,  stratified,  hard 
and  resistant  crust  at  the  bottom  of  the  pit,  which  has  to 
be  broken  up  with  a  pickaxe  and  removed  with  a  shovel. 
This  procedure  is  styled  'putting  the  finishing  touch.' 

In  the  Rue  St.  Dominique,  a  nightman  was  about  to 
undertake  the  cleaning  out  of  a  cesspool ;  while  he  was 
breaking  up  the  solid  faecal  crust,  he  was  exposed  to  the  gas 
which  was  given  off  (I  do  not  know  the  composition  of  this 
gas,  but  it  does  not  seem  to  me  to   be  simply  sulphuretted 


LESIONS  OF  THE  RESPIRATORY  SYSTEM.  187 

hydrogen),  then  he  staggered  and  fell.  His  comrades 
shouted  to  him  to  come  up,  and  one  of  them  descended  into 
the  cesspool  to  fetch  him,  but  he  fell  down  also.  These  two 
workmen  were  brought  up  again,  and  the  one  who  had  fallen 
first  was  the  first  to  be  restored  to  life,  by  means  of  artificial 
respiration — a  method  which  I  need  not  describe  in  detail 
here. 

In  the  second  accident,  the  same  series  of  events  occurred, 
but  this  time  only  one  workman  suffered. 

Well,  Gentlemen,  in  these  three  cases  the  workmen  took 
their  places  in  the  cart  after  they  had  recovered,  lit  their 
pipes,  and  returned  home  ;  they  ate  their  dinner,  went  to 
bed,  and  in  a  few  hours  they  died  of  capillary  bronchitis. 

What  has  the  medical  jurist  to  do  with  scch  cases  as 
these  ?  He  may  be  consulted  because  the  insurance  com- 
panies refuse  to  pay  the  claims.  The  company  admits 
having  assured  the  workman  against  accident,  but  it  de- 
clares that  it  is  not  responsible  here,  inasmuch  as  the 
workman  died  in  bed,  and  not  while  working  in  the  cesspool, 
and  that  between  the  time  of  the  accident  and  the  com- 
mencement of  the  catarrh  several  hours  had  elapsed,  during 
which  the  man  appeared  to  be  in  good  health. 

I  had  some  difficulty  in  getting  the  responsibility  of  the 
insurance  company  acknowledged  in  these  cases.  I  suc- 
ceeded because  the  two  accidents  happened  within  a  few 
weeks  of  each  other,  because  I  was  directed  to  conduct  the 
medico-legal  investigation  in  all  three  cases,  and  because  I 
had  to  deliver  my  reports  to  the  same  magistrates,  so  that  I 
could  more  easily  persuade  them  to  share  my  conviction. 

D.  Pulmonary  Phthisis. — Pulmonary  phthisis  may  be  a 
cause  of  sudden  death ;  I  have  already  spoken  to  you  of 
cases  of  this  kind  when  dealing  with  thrombosis,  embolism 
and  profuse  hemoptysis.  But  besides  ordinary  phthisis  we 
may  have  acute  tuberculosis. 

You  will  sometimes  have  to  deal  with  cases  in  which 
persons  are  accused  of  a  crime  because  some  one  has  died 
in  their  presence,  in  circumstances  which  the  law  regards  as 
suspicious.  And  you  will  find,  at  the  autopsy,  that  the  lungs 
of  the  so-called  victim  are  studded  with  tubercular  granula- 


SUDDEN  DEATH. 


tions.  A  young  tripe-seller,  20  years  of  age,  was  busy  pre- 
paring some  tripe  for  a  customer  at  his  stall  in  the  market. 
The  customer  was  stretching  out  his  hand  to  take  the  tripe 
which  the  dealer  was  handing  to  him,  when  at  the  same 
moment  the  latter  fell  backwards,  striking  his  head  against 
the  edge  of  a  table,  and  his  blood  streamed  out.  The  buyer 
hastened  to  procure  assistance  ;  but  his  actions  gave  rise 
to  the  idea  that  there  had  been  a  struggle.  The  police 
stepped  in,  and  the  customer  was  arrested,  while  the  body  of 
the  tripe-seller — for  he  was  dead — was  conveyed  to  the 
Morgue.  At  the  autopsy  I  ascertained  that  both  lungs  were 
stuffed  with  tubercle  ;  they  even  stood  upright  on  the  slab. 
At  the  inquest  evidence  was  given  that  the  tripe-seller,  who 
was  addicted  to  alcohol,  had  been  at  work  all  the  preceding 
night.  No  one  in  his  vicinity  had  ever  heard  him  cough  ;  no 
one,  not  even  he  himself,  suspected  that  he  was  tuberculous. 
Alcohohsm  was  the  principal  factor  in  the  latent  course 
pursued  by  the  tuberculosis.  Remember,  then,  that  tuber- 
cular phthisis  may  run  its  course  without  manifesting  any 
symptom. 

Shall  I  relate  another  case  to  you  ?  A  child,  12  years  old, 
whom  his  master  had  struck  on  the  head  with  a  ruler,  died 
suddenly.  The  master  was  accused  of  having  caused  the 
child's  death.  Post-mortem,  the  lungs  and  meninges  were 
found  full  of  granulations.  It  is  evident  that  the  master  had 
no  right  to  strike  the  child  with  the  ruler,  but  this  slight 
blow  had  nothing  whatever  to  do  with  the  production  of  the 
pulmonary  and  meningeal  lesions. 

Is  it  possible  for  sudden  death  to  occur  in  double  pneumo- 
thorax ? 

Bricheteau  has  reported  two  such  cases.*  M.  Duguet  has 
recorded  a  third.     These  are  the  only  cases  that  I  know  of. 

E.  Cancer  of  the  Lung. — This  is  a  painful  affection  of 
slow  progress,  and  is  accompanied  by  attacks  of  suffocation, 
and  by  sputum  of  characteristic  colour.  I  only  know  of  one 
case  of  sudden  death  from  this  disease  which  has  given  occa- 
sion for  an  inquest. 

The  accused  person  in  this  case  was  a  chemist,  who  had 
*  Bricheteau,  '  Clinique  mddicale.' 


LESIONS  OF  THE  RESPIRATORY  SYSTEM.  189 

given  two  pills  to  a  gentleman  who  had  consulted  him,  and 
who  had  died  suddenly  after  swallowing  the  pills.  The 
chemist  was  prosecuted  for  illegal  practice  of  medicine,  and 
for  making  a  mistake  in  the  drugs  he  had  sold.  The  autopsy 
having  revealed  the  existence  of  cancer  in  the  lung  of  the 
deceased,  the  prosecution  was  abandoned. 

F.  Emphysema  of  the  Lungs.  —  Piedagnel  wrote  his 
inaugural  thesis  on  sudden  death  in  pulmonary  emphy- 
sema. He  collected  the  reports  of  thirty  cases,  which  were 
published  not  long  ago.  I  should  like  to  make  the  same 
remarks  with  reference  to  emphysema  that  I  did  in  the  case 
of  pulmonary  congestion.  I  do  not  believe  that  emphy- 
sema alone,  apart  from  any  other  lesion,  can  lead  to  sudden 
death,  any  more  than  simple  pulmonary  congestion  can 
do  so. 

G.  Pleurisy. — Of  all  pulmonary  affections,  pleurisy  causes 
the  greatest  number  of  sudden  and  unforeseen  deaths.  They 
frequently  occasion  medico-legal  investigations.  These  cases 
of  sudden  death  may  be  divided  into  two  categories,  accord- 
ing to  the  process  by  which  death  is  brought  about :  one  of 
these  has  been  well  described  by  Aran,  physician  to  the  St. 
Antoine  Hospital ;  the  existence  of  the  other  has  been 
demonstrated  by  a  large  number  of  observers. 

Aran  was  struck  by  this  case:  A  young  man,  aged  25,  came 
to  his  consulting-room  one  day  quite  out  of  breath.  He 
called  himself  an  '  arthritic,'  and  ascribed  his  symptoms  of 
oppressed  breathing  to  that  diathesis.  Aran  made  him 
undress,  examined  his  chest,  and  ascertained  the  presence  of 
pleuritic  effusion  reaching  up  to  the  middle  of  the  infraspinous 
fossa.  He  told  the  patient  to  get  home  and  go  to  bed,  and 
as  the  latter  consented  to  have  paracentesis  performed,  he 
would  come  and  perform  it  immediately. 

At  the  very  moment  that  Aran  reached  the  house  the 
patient  died. 

There  are  cases  of  latent  pleurisy,  where  the  effusion  takes 
place  gradually,  where  there  is  only  slight  shortness  of 
breath,  without  severe  attacks  of  suffocation,  which  are  the 
most  frequent  causes  of  sudden  death.  I  have  seen  thirty 
such  cases  at  the  Morgue  since  1876. 


I90  SUDDEN  DEATH. 


Besides  these  cases  of  pleurisy  with  very  abundant  sero- 
fibrinous effusion,  there  are  others  with  less  fluid,  sometimes 
purulent,  and  involving  the  diaphragm,  which  cause  sudden 
death. 

The  pathogeny  of  this  form  of  sudden  death  has  given  rise 
to  lengthy  discussion.  It  has  been  ascribed  to  displacement 
of  the  heart,  the  theory  being  that,  when  the  apex  of  the 
heart  is  displaced  to  the  right  by  effusion  on  the  left  side, 
the  heart  is  so  twisted  thereby  that  its  action  is  interfered 
with,  and  that  sudden  death  may  result  from  this  abnormal 
condition.  Now,  pleuritic  effusion  is  at  least  as  common  on 
the  right  side  as  on  the  left. 

Torsion  of  the  aorta  has  also  been  credited  with  causing 
the  disaster,  but  without  any  more  reason. 

Embolism  has  also  been  mentioned.  Two  cases  might 
appear  to  corroborate  this  view.  The  first  is  that  of  Dr. 
Wood,  an  American.  He  relates  that  an  individual 
became  suddenly  hemiplegic  and  aphasic  in  the  course 
of  an  attack  of  pleurisy,  from  embolism  of  the  middle 
cerebral  artery.  The  second  case  is  that  of  M.  Vallin,* 
who  reports  a  case  which  is  identical  with  Dr.  Wood's. 

In  both  cases  the  embolus  came  from  the  pulmonary 
veins  ;  the  clot  which  had  been  broken  off  entered  the  left 
side  of  the  heart,  passed  into  the  arterial  system,  and  blocked 
the  middle  cerebral  artery.  These  cases  therefore  confirm 
the  theory,  which  is  possibly  correct.  But  can  this  sole 
explanation  be  applied  to  all  cases  of  sudden  death  in 
pleurisy  ?     That  is  a  very  different  matter. 

Gentlemen,  when  one  lung  is  no  longer  able  to  perform 
its  work,  the  other  is  obliged  to  carry  on  the  whole  of  the 
lesser  circulation.  The  quantity  of  blood  that  is  necessary 
to  maintain  circulation  has,  therefore,  only  one  lung  at  its 
disposal,  and  this  organ  has  almost  double  work  to  perform; 
suppose,  then,  that  from  any  cause  the  circulation  of  blood 
in  the  healthy  lung  is  obstructed,  hypersemia  or  congestion 
must  follow,  which  may  cause  sudden  death  :  post-mortem  in 
such  cases,  apoplectic  nodules  are  found.  I  do  not  main- 
tain that  this  is  the  sole  cause  of  sudden  death  in  pleuris}^ 
*  Vallin,  Soc.  vied,  des  Hop.^  1871,  and  Gaz.  liebd.  de  Med. 


LESIONS  OF  THE  RESPIRATORY  SYSTEM.  191 

but  I  am  sure  that  it  is  one  of  the  causes,  since  I  have  found 
in  many  instances,  post-inorteni,  that  the  healthy  lung  is  con- 
gested and  full  of  apoplectic  foci. 

Woillez*  has  reported  some  cases  of  sudden  death  occur- 
ring in  the  course  of  pleurisy.  Read  these  reports  over 
again,  and  you  will  find  in  his  accounts  of  the  post-mortem 
appearances,  which  are  described  with  the  great  care  charac- 
teristic of  Louis's  pupils,  the  exact  lesions  that  I  have  pointed 
out  to  you. 

They  have  not  struck  Woillez  in  the  same  light,  however, 
nor  has  he  attached  more  importance  to  the  discovery  of 
apoplectic  foci  in  a  healthy  lung. 

Lastly,  in  some  cases  there  is,  along  with  the  effusion, 
fatty  degeneration  of  the  heart,  adherent  pericardium,  etc. ; 
we  are  entitled  to  regard  these  lesions  as  contributing  to 
bring  about  sudden  death. 

From  the  point  of  view  of  forensic  medicine,  the  questions 
are  often  embarrassing.  Answer  them  for  yourselves  in  the 
following  instance  : 

A  policeman  arrested  a  man :  the  latter  resisted,  and 
aimed  a  blow  with  his  fist  at  the  chest  of  the  officer,  who 
fell  down  dead ;  witnesses  saw  the  blow  struck,  and  the 
arrested  man  admitted  having  delivered  it. 

On  opening  the  thorax,  a  considerable  amount  of  pleuritic 
effusion  was  found,  compressing  the  right  lung.  The  officer 
was  therefore  in  danger  of  sudden  death  at  the  moment  when 
he  was  making  the  arrest.  Was  it,  therefore,  justifiable  to 
say  that  the  blow  had  caused  death  ?  At  any  rate,  it  was 
only  the  exciting  cause. 

Sudden  death  may  happen  during  the  operation  of  para- 
centesis thoracis;  it  is  less  common  nowadays  than  formerly, 
when  fewer  precautions  were  taken  about  the  operation. 
While  I  was  house-physician  I  had  one  day  to  assist  one  of 
my  masters  in  performing  paracentesis  :  the  patient  was  a 
wealthy  banker,  and  four  professors  of  the  Faculty  were 
present  at  his  bedside  ;  a  number  of  basins  were  in  readiness 
to  receive  the  fluid  that  was  to  be  drawn  off.  The  needle 
was  entered,  but  without  result;  the  puncture  was  repeated 
*  Woillez,  '  Traits  des  Maladies  des  Voies  respiratoires.' 


192  SUDDEN  DEATH. 


twice  more,  but  still  without  any  success  ;  and  at  the  end 
of  a  quarter  of  an  hour  the  physicians  went  away  without 
one  of  the  basins  having  been  wetted.  In  six  hours  the 
patient  suddenly  began  to  expectorate  a  large  quantity  of 
albuminous  fluid,  and  died. 

Legroux,  Marotte  and  others  have  expressed  the  opinion 
that  death  during  paracentesis  is  due  to  syncope.  The 
patient  is  usually  seated  on  his  bed  ;  in  proportion  as  the 
pleuritic  fluid  escapes  there  is  a  rush  of  blood  towards  the 
lungs,  and  syncope  follows  from  cerebral  ansemia.  This  is 
possible. 

Since  we  have  had  more  perfect  instruments,  and  as  we 
can  repeat  the  aspiration  from  time  to  time,  we  do  not  com- 
pletely evacuate  the  cavity,  and  we  no  longer  exhaust  it  by 
removing  all  the  effused  fluid.  When  the  proper  point  is 
exceeded  and  an  excess  of  liquid  is  withdrawn,  considerable 
pulmonary  congestion  ensues,  and  as  a  consequence  there  is 
bronchial  over-secretion,  just  as  in  'suffocating  catarrh';  it 
is,  however,  much  more  albuminous,  doubtless  owing  to 
exudation  of  blood  serum  into  the  alveoli  of  the  lung. 

M.  Terrillon  has  made  a  study  of  these  cases;*  he  has 
collected  about  thirty  of  them,  all  nearly  identical.  The 
individual  on  whom  paracentesis  is  performed  is  seized  with 
a  spasmodic  cough;  the  operation  is  not  proceeded  with; 
the  patient  is  put  to  bed.  On  feeling  his  pulse,  there  is 
nothing  to  give  warning  of  any  accident.  An  hour  after  the 
patient  coughs  up  an  extraordinary  amount  of  liquid  from 
his  bronchial  tubes,  and  dies  suffocated. 

Such  accidents  scarcely  ever  happen  now,  since  the  opera- 
tion is  not  pushed  so  far  now  as  it  used  to  be.  However, 
they  do  occur  occasionally,  and  the  responsibihty  of  the 
physician  or  surgeon  will  be  called  in  question.  In  cases  of 
the  sort,  I  shall  always  remain  faithful  to  the  rule  that  it  is 
wise  to  leave  some  fluid  behind  in  the  pleural  cavity,  but  I 
should  not  think  it  a  serious  error  if  the  physician  should  go 
a  little  farther.  It  depends  on  an  estimation  of  the  nature 
of  the  case.     The  amount  of  fluid  in  the  pleura  cannot  be 

*  Terrillon,  '  De  I'Expectoration  albumineuse  apres  la  Thoracentese.' 
These  inaug.     Paris,  1873. 


LESIONS  OF  THE  RESPIRATORY  SYSTEM.  193 

known  exactly  ;  it  is  easy  to  make  a  mistake.  Anyone  who 
declares  that  there  are  5  pints  effused  may  only  find  i|-  or 
2  pints,  while  another  who  believes  that  there  is  only  an 
insignificant  effusion  may  be  astonished  at  having  to  with- 
draw 3I  or  5  pints.  It  seems  to  me,  therefore,  quite 
unjustifiable  to  hold  a  fellow-practitioner  responsible  for  an 
error  of  this  kind. 

Accidents  of  another  kind  have  been  described  by 
Raynaud  and  myself.  They  may  take  place  while  washing 
out  the  pleural  cavity,  or  during  the  injection  of  iodine,  etc. 
In  such  circumstances  epileptiform  convulsions  may  occur, 
but  I  do  not  think  that  they  have  ever  caused  sudden  death. 
Moreover,  they  do  not  seem  to  be  met  with  now  that  the 
operation  of  paracentesis  is  performed  with  greater  skill  and 
precision. 

H.  Rupture  of  the  Diaphragm. — I  ought  to  say  a  few 
words  to  you  about  rupture  of  the  diaphragm.  It  is  neces- 
sary that  you  should  know  that  it  may  exist.  How  is  it 
produced  ?  It  is  very  difficult  to  say  exactly,  partly  because 
it  is  an  extremely  rare  condition,  partly  because  it  is  very 
difficult  to  ascertain  whether  or  not  there  has  been  a  con- 
genital hernia.  In  cases  of  sudden  death,  with  or  without 
violence,  a  portion  of  the  abdominal  viscera  may  be  found 
intruding  in  the  pleural  cavity  ;  it  is  not  always  easy  to  say 
what  was  the  exact  state  of  the  organs  that  existed  before 
the  final  accident.  M.  Duguet*  has  recorded  17  cases  of 
rupture  of  the  diaphragm,  and  I  would  advise  you  to  read 
his  very  interesting  memoir,  discussion  of  which  now  would 
detain  us  too  long. 

*  Duguet,   '  De  la    Hernie  diaphragmatique  congenitale.'     These  de 
doctorat.     Paris,  1866. 


13 


LECTURE  V. 

MODIFICATIONS  OF  VASCULAR  TENSION :  THEIR  ACTION 
AS  AUXILIARY  CAUSES,  OR  AS  EFFICIENT  CAUSES 
(WHEN  IN  EXCESS). 

Gentlemen, — Certain  influences  play  an  important  part  in 
the  causation  of  sudden  death.  Their  mode  of  action  is  to 
produce  changes  in  vascular  tension.  With  your  per- 
mission, I  will  distinguish  between  their  modes  of  operation 
as  follows  : 

I.  AUXILIARY  CAUSES  :   EFFORT,   COLD,   HEAT. 

Many  persons  think  that  heat  and  cold  are  the  two  prime 
factors  of  sudden  death.  This  is  true  to  a  certain  extent. 
Heat  and  cold  frequently  determine  sudden  death  in  those 
who  are  the  subjects  of  some  lesion  which  places  them  in 
a  position  of  physical  inferiority  and  prevents  them  from 
successfully  resisting  such  influences.  But,  as  a  rule,  heat 
and  cold  only  act  as  contributory  causes. 

There  are  other  cases  where,  apart  from  any  concomitant 
lesion,  heat  or  cold  may  determine  sudden  death.  Post- 
mortem you  w^ill  only  find  healthy  organs,  and  the  problem 
you  have  to  solve  will  be  difficult. 

When  these  influences  are  exerted  in  an  accessory  capacity, 
we  may  sum  them  all  up  in  the  same  formula  :  they  bring 
about  some  modification  in  vascular  tension.  They  com- 
prise effort,  the  process  of  digestion,  cold,  and  heat. 

You  know  what  effort  signifies.  The  muscles  of  the  chest 
are  contracted ;  respiration  is  performed  by  the  diaphragm 
only ;  all  the  viscera  within  the  chest  are  as  motionless  as 


MODIFICATIONS  OF  VASCULAR  TENSION.  195 

possible,  in  order  that  the  individual  may  have  a  firm  basis 
from  which  his  muscles  may  act.  See  what  happens  in 
coughing  :  the  walls  of  the  chest  are  fixed  ;  the  diaphragm 
alone  acts;  the  body  becomes  stiff;  vascular  tension  is 
increased  ;  the  veins  swell ;  the  face  gets  red.  If  there  is 
any  locus  minoris  resistenticE  in  the  circulatory  system,  e.g.,  a 
miliary  aneurysm  in  the  brain,  it  may  burst,  and  its  rupture 
may  cause  sudden  death.  Cases  of  this  sort  have  been 
noticed  during  parturition,  in  the  fits  of  whooping-cough,  in 
defsecation,  and  even  during  coitus. 

While  the  process  of  digestion  is  going  on,  there  is  equally 
an  increase  of  vascular  tension.  It  has  been  noticed  that 
cerebral  haemorrhage  often  takes  place  after  a  meal,  especi- 
ally if  much  has  been  taken  to  drink.  By  drinking  two  or 
three  pints  of  liquid,  which  is  not  an  exaggerated  amount,  the 
vascular  tension  is  raised,  and  a  vessel  may  give  way  before 
the  kidneys  have  had  time  to  dispose  of  the  surplus  by  secre- 
tion of  urine,  thus  restoring  the  tension  to  its  normal  degree. 

As  to  variations  of  temperature,  it  is  certain  that  sudden 
death  is  most  frequent  during  the  winter  months. 

When  sudden  death  is  due  to  the  influence  of  heat  or  cold, 
the  mechanism  by  which  death  is  produced  is  not  the  same 
in  both  cases.  Understand,  Gentlemen,  that  I  am  only  speak- 
ing now  of  such  temperatures  as  we  meet  with  in  France. 

Under  the  action  of  somewhat  intense  heat,  the  capillaries 
dilate,  the  skin  gets  red  and  covered  with  perspiration.  The 
dilatation  of  the  capillaries  lowers  the  vascular  tension  ;  the 
pulse  remains  regular,  but  is  more  frequent.  When  the 
vascular  dilatation  is  considerable,  and  the  heart  is  weakened 
by  any  cause  whatever — in  persons  suffering  from  aortic 
incompetence,  for  example — it  may  produce  fatal  syncope. 

The  action  of  cold  shows  itself  in  the  contrary  way.  The 
capillaries  contract  instead  of  dilating  ;  intra-vascular  tension 
is  increased  ;  the  pulse  is  less  frequent.  It  causes  a  reflux 
of  blood  to  the  central  organs,  and  if  any  vessel  is  weakened 
it  will  burst.  This  is  what  happens  in  those  who  suffer  from 
aneurysm,  particularly  miliary  aneurysm. 

In  both  cases  heat  and  cold  only  act  as  auxiliaries  to  some 
pre-existing  cause. 


196  SUDDEN  DEATH. 


II.  EFFICIENT  CAUSES  :  COLD,  HEAT. 

These  agents  may  be,  in  a  certain  number  of  cases,  the 
sole  factors  of  death.  They  may  become  efficient  causes  by 
their  excess.  A  body  is  found  by  the  roadside:  what  is  the 
cause  of  death  ?  Nothing  but  2.  post-mortem  examination  will 
supply  you  with  facts  which  will  enable  you  to  decide  whether 
death  may  be  due  to  heat  or  to  cold.  You  ought  to  be  able 
to  deliver  a  reasoned  opinion,  and,  in  order  to  do  this,  you 
should  know  first  of  all  that  an  excessive  temperature  is 
not  indispensable.  Heat  and  cold  may  kill  without  the 
thermometer  registering  abnormal  temperatures. 

A.  Heat. — Let  us  first  consider  death  due  to  heat  alone. 
It  has  been  said  that  it  may  be  due  to  sunstroke  or  heat- 
stroke;  there  is  no  great  difference  between  them.  Of 
course,  I  exclude  that  trifling  effect  of  insolation  which  is 
common  in  our  climate,  and  which  shows  itself  by  erythema 
of  the  skin,  and  is  devoid  of  danger. 

We  know  but  little  of  sunstroke  in  France;  but  it  is  very 
frequent  in  America.  In  New  York  it  kills  20  or  30  persons 
every  year.  There  are  more  victims  of  sunstroke  in  New 
York  than  in  any  other  city  in  the  world. 

In  heatstroke,  on  the  contrary,  it  is  not  the  solar  radiation 
which  kills.  People  are  found  dead  in  the  shade  of  a  wood 
or  under  a  tent,  while  the  thermometer  registers  97°  F.  in 
the  shade.     The  heat  is  a  moist  one. 

In  sunstroke  the  symptoms  resemble  those  of  meningitis. 
In  persons  thus  struck  we  meet  with  delirium,  cerebral  dis- 
turbance (which  were  formerly  designated  'frenzy,'  or 
'  phrenitis '),  and  sometimes  vomiting.  Claude  Bernard* 
and  M.  Vallin  have  experimented  on  this  subject,  but  their 
results  were  not  very  decisive.  CI.  Bernard  shut  animals  up 
in  boxes,  only  the  head  being  outside  the  apparatus,  and 
exposed  to  the  sun.  The  animals  subjected  to  these  experi- 
ments showed  symptoms  like  those  of  meningitis  after  a 
certain  time  ;  but  an  animal  placed  in  these  conditions  can- 
not move — its  body,  confined  in  a  box,  cannot  liberate  the 
heat  which  is  stored  up  in  it.  It  is  no  longer  in  the  same 
situation  as  an  animal  that  is  free  to  move  about  as  it  likes, 
*  Claude  Bernard,  '  Lecons  sur  la  Chaleur  animale.'     Pari?,  1876. 


MODIFICATIONS  OF  VASCULAR  TENSION.  197 

and  the  results  of  the  experiments  to  which  they  were  sub- 
mitted ought  to  be  accepted  with  great  reserve. 

Heatstroke  is  very  prevalent  in  India ;  it  is  from  that 
country  that  the  descriptions  of  it  come.  In  France  we  had 
our  first  opportunity  of  studying  it  about  i856,  and  the  earliest 
cases  that  were  met  with  were  misunderstood.  x\t  that  time  the 
Suez  Canal  was  nearly  finished,  and  the  ships  began  to  bring 
back  to  Europe  the  labourers  and  soldiers  who  had  served 
in  the  East.  On  board  several  of  these  ships  some  of  the 
passengers  suffered  from  a  singular  form  of  illness.  These 
individuals,  who  were,  moreover,  in  an  excessively  hot 
atmosphere  (104°  F.  in  the  shade),  spent  the  day  in  their 
cabins.  Some  of  them,  who  had  been  in  good  health 
hitherto,  were  seized,  on  leaving  the  table,  with  attacks  of 
delirium  and  frenzy  ;  they  wished  to  jump  overboard,  and 
they  died  speedily. 

These  phenomena  were  regarded  as  attacks  of  pernicious 
fever  supervening  in  persons  who  had  lived  in  hot  climates, 
and  who  had  formerly  suffered  from  intermittent  fever  there. 
This  was  the  explanation  given  by  M.  Texier.  It  has  had  to 
be  abandoned.  We  are  now  convinced  that  the  attacks  were 
only  cases  of  heatstroke,  and  it  is  now  found  necessary  to 
take  negroes  as  stokers  on  board  ships  passing  through  the 
Red  Sea,  for  none  but  they  can  resist  the  intensity  of  the 
heat  which  prevails  in  the  stokehole. 

Besides  these  fatal  cases  which  take  place  in  distant 
regions,  we  had,  even  in  Paris,  in  1877,  some  sad  cases 
which  may  help  to  elucidate  the  nature  of  the  disorder. 
When  the  review  of  July  14  was  over,  the  troops  were  dis- 
banded, and  returned  to  their  cantonments.  Some  regiments 
retired  to  the  woods  of  St.  Cloud  or  Vaucresson.  The  men 
were  disposed  to  rest  themselves  there,  and  many  were 
seized  with  genuine  heatstroke.  Dr.  Pioche,  who  was  then 
a  military  surgeon,  has  contributed  a  complete  account  of 
these  cases.  He  relates  that  no  sooner  had  the  men  re- 
moved their  knapsacks  than  they  fell  down  panting,  with 
their  faces  flushed  and  anxious,  and  some  of  them  died.  It 
is  a  curious  fact  that  the  non-commissioned  officers  especially 
were  selected  as  victims. 


SUDDEN  DEATH. 


The  question  of  clothing  has  very  much  to  do  with  "the 
production  of  heatstroke.  During  the  Chinese  War,  two 
battalions  took  part  in  the  military  operations  from  the 
beginning  of  the  campaign.  The  men  of  one  of  these  bat- 
tahons  still  wore  the  cloth  uniform  which  they  had  worn  in 
Europe ;  those  of  the  other  battalion  had  been  supplied  with 
the  colonial  dress.  Among  the  latter  no  accident  was  met 
with ;  among  the  former,  on  the  contrary,  the  heat  made 
numerous  victims.  In  all  other  respects  they  were  equally 
exposed. 

People  may  die  of  heatstroke  in  a  conflagration.  This 
fact  was  proved  to  us  when  the  Opera  Comique  was  burnt. 
I  am  well  aware  that  the  production  of  carbonic  oxide  must 
be  taken  mto  account  in  such  conditions.  But  the  lungs 
cannot  long  withstand  the  introduction  of  air  heated  to 
104°  or  122°  F.,  even  if  this  air  contains  no  carbonic  oxide. 

Dr.  Speck*  has  reported  the  following  case :  A  girl  com- 
plained of  rheumatic  pains.  She  was  put  to  bed,  and  ten 
loaves  of  bread  fresh  from  the  oven  were  placed  around  her. 
At  the  end  of  three  hours,  the  unfortunate  girl  was  dead. 
She  had  succumbed  to  the  hot  vapours  exhaled  by  the  loaves 
of  bread. 

In  connexion  with  such  examples  as  these,  those  fatal 
accidents  should  be  considered  which  may  suddenly  befall 
individuals  in  a  vapour  bath.  You  may  be  called  upon  to 
make  medico-legal  investigations  in  cases  of  this  kind. 
Without  speaking  to  you  of  that  woman  who  was  found 
dead  in  a  bath-room,  the  temperature  of  which  was  187°  F., 
and  where  the  steam -jet  remained  open,  there  are  less 
extreme  cases,  where  the  temperature  is  not  too  high,  but 
where  the  individuals  who  suffer  have  not  been  able  to 
endure  it  long.  I  do  not  know  whether  these  individuals 
had  any  constitutional  defect,  which  is  the  main  factor,  or  at 
any  rate,  a  potent  predisposing  cause,  of  sudden  death  :  but 
I  know  that  under  any  circumstances  vapour  baths,  with  a 
temperature  of  158°  to  185°  F.,  give  rise  to  accidents  so 
frequently  that  I  do  not  dare  to  recommend  them. 

What  is  the  modus  operandi  of  heat  when  it  determines 
*  '  Cas  de  Mort  par  la  Chaleur'  {Attn,  d' Hyg.,  1876,  tome  xlvi.,  p.  561). 


MODIFICATIONS  OF  VASCULAR  TENSION.  199 

death  in  these  conditions,  i.e.,  in  India,  or  in  the  stokehole 
of  a  ship  ?  When  the  heat  becomes  considerable,  the 
capillaries  of  the  skin  and  of  the  lungs  dilate ;  intravascular 
tension  is  lowered,  and  the  skin  is  bathed  in  perspiration. 
While  the  skin  perspires,  the  lungs  eliminate  a  still  larger 
amount  of  water.  Observe,  Gentlemen,  that  when  an  in- 
dividual suffering  from  pneumonia  or  typhoid  fever  has  a 
dry  tongue,  it  is  because  he  no  longer  eliminates  watery 
vapour  by  his  lungs. 

The  organism  gives  off  watery  vapour  as  a  defence  against 
the  heat.  But  when  the  external  air  is  saturated  with 
moisture,  the  organism  can  continue  the  struggle  no  longer, 
the  lungs  can  no  longer  eliminate  water,  the  beats  of  the 
heart  increase  in  frequency,  its  sounds  become  indistinct, 
and  it  stops ;  while  the  axillary  temperature  runs  up  to 
104°  F.,  or  even  113°  F.  ;  the  individual  is  literally  baked, 
and  he  dies. 

The  process  is  identical  with  that  in  a  porous  earthenware 
carafe ;  the  water  in  the  interior  of  the  vessel  is  chilled  by 
the  evaporation  of  that  which  percolates  to  the  outer  surface. 
When  the  atmosphere  is  dry,  and  the  body  is  kept  more  or 
less  in  motion,  much  higher  temperatures  can  be  borne  than 
in  a  confined  place  where  the  heat  is  moist. 

The  lesions  found  post-mortem  are  those  of  pulmonary  con- 
gestion. Hestrez  has  very  fairly  compared  the  lungs  to  two 
bags  of  blood  ;  the  bronchi  are  full  of  froth.  The  blood 
remains  black,  though  in  contact  with  air  and  oxygen  ;  it  no 
longer  becomes  arterial,  therefore  the  corpuscles  must  have 
undergone  a  profound  alteration.  It  is  very  important  for 
the  medical  jurist  to  be  aware  of  this  fact,  because  it  is 
always  possible  at  an  autopsy,  except  after  certain  forms 
of  poisoning,  or  when  putrefaction  is  already  advanced,  to 
restore  the  red  colour  to  the  blood.  In  this  case  it  is  no 
longer  possible  to  do  so. 

The  nervous  system  suffers  severely.  Vallin  has  insisted 
that  these  patients  are  insensible.  They  have  headache, 
become  dehrious,  then  comatose,  and  die.  The  pupils  are 
contracted  at  first,  but  dilate  widely  in  the  last  moments  of 
hfe. 


SUDDEN  DEATH. 


In  1844,  during  the  conquest  of  Algeria,  General  Bugeaud, 
who  led  a  column  of  3,000  soldiers,  was  exposed  to  an  ex- 
treme temperature;  he  lost  200  men,  eleven  of  whom  com- 
mitted suicide  in  the  space  of  three  hours.  Ideas  of  suicide 
are,  as  a  matter  of  fact,  common  in  individuals  suffering 
from  heatstroke,  especially  if  they  are  alcoholic  subjects. 

Gentlemen,  when  the  temperature  of  a  muscle  is  raised, 
certain  phenomena  are  observed  which  I  ought  to  bring 
to  your  notice ;  they  have  been  shown  very  clearly  by 
M.  Marey's  registering  apparatus.  When  this  instrument 
is  attached  to  a  frog's  thigh,  the  animal's  muscles  are 
tapped  several  times,  and  the  contraction  which  follows 
each  tap  is  marked  on  the  register ;  in  proportion  as  the 
muscle  is  warmed,  the  curve  diminishes  in  amplitude,  and 
soon  becomes  a  straight  line,  and  although  the  taps  are 
repeated,  the  line  remains  horizontal.  Kiihne  of  Heidelberg 
has  explained  the  phenomenon  by  the  coagulation  of  myosin. 
Others  have  ascertained  the  presence  of  lactic  acid  in  the 
muscles  of  the  frog,  just  as  in  over-driven  animals.  M.  Vallin 
observes  that,  in  animals  exposed  to  the  full  heat  of  the  sun's 
rays,  the  heart  stops  in  systole  ;  if  the  animal  is  killed  im- 
mediately, M.  Vallin  finds  the  left  side  of  the  heart  so  hard 
as  to  deserve  the  epithet  '  ligneous.' 

As  regards  the  secretions,  there  are  only  two  which  offer 
any  point  of  interest  :  at  the  commencement  of  heatstroke, 
perspiration  is  profuse,  then  it  stops ;  the  urine,  on  the  con- 
trary, is  scanty  at  first,  but  becomes  abundant  (polyuria) 
when  the  skin  no  longer  acts.  Morehead  has  pointed  out 
the  frequency  and  intensity  of  this  desire  to  urinate.  Gubler 
states  that  he  has  found  albumen  and  sugar  in  cases  of  this 
class. 

I  should  find  myself  in  considerable  difficulties.  Gentle- 
men, if  I  were  obliged  to  give  an  opinion,  founded  simply 
on  post-mortem  examination,  on  the  cause  of  death  in  a 
medico-legal  investigation  of  a  fatal  case  of  heatstroke. 
These  cases  happen  more  often  in  the  provinces  than  in 
Paris.  Do  not  forget  to  inquire  under  what  circum.stances 
the  person  died ;  find  out  whether  he  had  been  eating  or 
drinking;  go  and  examine  for  yourself  the  wood  in  which 


MODIFICATIONS  OF  VASCULAR  TENSION.  201 

the  body  was  found  ;  ascertain  the  temperature,  the  force 
and  direction  of  the  wind,  the  moisture  of  the  air,  etc.,  on 
the  day  when  death  occurred.  These  details  are  of  import- 
ance, for  examination  of  the  body  will  only  afford  presumptive 
evidence. 

B.  Cold. — Death  from  cold  is  more  common  than  that 
from  heat.  In  Russia  cold  kills  about  700  persons  annually. 
M.  Lacassagne*  estimates  that  we  lose  in  France  on  an 
average  200  men  and  50  women  annually  from  cold. 

This  proportion  is  easily  explained  :  the  occupations  of 
men  expose  them  more  than  women  to  external  cold. 

An  experiment  of  Magendie's  explains  in  a  very  suggestive 
way  the  mechanism  of  death  from  cold.  He  shut  up  a  rabbit 
in  a  cage,  the  temperature  of  which  was  maintained  at  32"  F. ; 
in  five  minutes  the  temperature  of  the  rabbit  had  fallen  5F  ; 
in  a  quarter  of  an  hour  it  had  fallen  11°  ;  and  in  40  minutes 
it  had  fallen  36°,  and  the  animal  died.  It  is  easy  to  under- 
stand why  this  happens.  Under  the  influence  of  cold  the 
capillaries  contract  and  vascular  tension  is  increased.  As 
the  resistance  augments,  the  action  of  the  heart  becomes 
slower.  As  long  as  the  peripheral  capillaries  are  contracted 
the  body  does  not  cool  much,  for  the  blood  does  not  reach 
the  surface,  and  thus  part  with  its  heat  by  radiation  ;  but 
when  the  contractile  force  of  the  capillaries  is  exhausted, 
they  dilate,  blood  rushes  to  the  surface,  and  gives  up  a  great 
deal  of  its  heat. 

You  know  that  when  you  make  snowballs  your  hands  are 
cold  at  first,  but  afterwards  become  red  and  warm,  the 
capillaries  being  dilated.  It  is  the  same  with  the  cold 
douche.  The  jet  of  cold  water  makes  the  capillaries  con- 
tract;  they  should  not  dilate  until  the  douche  is  over,  in 
order  that  it  may  prove  beneficial.  But  if  the  individual 
becomes  warm  under  the  douche,  to  use  the  douchers'  ex- 
pression— i.e.fiiihe  capillaries,  which  were  at  first  contracted, 
dilate  while  still  exposed  to  the  jet  of  cold  water — he  turns 
bljie,  the  blood,  chilled  by  the  cold  water,  returns  cold  to 
the  internal  organs,  and  the  situation  becomes  perilous. 

When  the  cold  is  intense,  frost-bite  may  occur  ;  the  nose, 
*  Lacassagne,  '  Prdcis  de  Medicine  judiciaire.'     Paris,  1886. 


SUDDEN  DEATH. 


eyelids  and  ears  are  usually  the  first  portions  of  the  body  to 
suffer.  But  these  are  local  lesions,  which  are  quite  distinct 
from  our  present  subject. 

Our  physiological  resources  against  cold  are  limited. 
When  the  degree  of  cold  is  slight,  we  walk  more  briskly  ; 
we  feel  exhilarated ;  we  inhale  more  oxygen  and  exhale 
more  carbonic  acid. 

It  is  no  longer  so  when  the  cold  is  intense.  In  death  by 
cold  it  seems  as  if  combustion  is  arrested  ;  the  blood  re- 
mains crimson;  it  no  longer  contains  carbonic  acid,  and  it 
has  lost  its  coagulability.  The  chemical  changes  in  the 
body  are  therefore  very  much  disturbed. 

What  is  the  action  of  cold  upon  the  nervous  system  ?  If 
the  exposure  to  cold  has  been  of  long  duration,  the  indi- 
vidual has  no  recollection  of  what  has  passed ;  there  is 
amnesia  (which  has  been  well  described  by  M.  Motet*). 

At  the  outset  there  may  be  delirium,  there  is  often  a  pro- 
pensity towards  suicide,  and  always  a  tendency  to  sleep;  sen- 
sibility is  deadened  (remember  that  the  application  of  cold 
was  at  one  time  used  to  procure  local  anaesthesia  in  petty 
operations,  such  as  that  of  ingrowing  toe-nail)  ;  sight  is  dim  ; 
according  to  Gmelin,  the  retina  is  pale  and  the  lens  some- 
times frozen.  The  vaso-motor  system  is  also  affected. 
Weir  Mitchell  placed  a  bladder  of  ice  along  the  course  of 
the  ulnar  nerve ;  the  hand  became  cold,  then  the  capillaries 
dilated,  and  it  grew  red,  just  as  after  section  of  the  great 
sympathetic. 

The  muscles  contract  under  the  influence  of  slight  cold  ; 
remember  the  movements  of  the  cremaster  and  the  desire  to 
pass  urine,  which  you  can  prove  experimentally  on  yourselves. 
When  the  cold  is  keen,  the  muscular  contractions  last  longer, 
and  finally  stop  ;  Marey's  recording  instrument  has  made 
this  clear.  The  muscular  fibres  no  longer  contract  volun- 
tarily ;  the  individual  cannot  walk,  and  is  obliged  to  stop  ; 
he  becomes  stiff,  and  the  action  of  his  heart  ceases.  The 
urine,  which  is  abundant  at  first,  is  suppressed  at  last;  the 
skin  remains  dry,  and  there  is  no  perspiration. 

*  Motet,  '  Intoxication  par  I'Oxyde  de  Carbone,  auto-observation ' 
{A?tn.  d'Hyg.,  1894,  tome  xxxi.,  p.  258). 


MODIFICATIONS  OF  VASCULAR  TENSION.  203 

Larrey  has  given  a  masterly  description  of  death  from  cold 
in  his  account  of  the  retreat  from  Russia  ;  I  cannot  resist 
the  temptation  of  reading  a  few  lines  of  it  to  you  : 

'  We  were  all  in  such  a  state  of  prostration  and  torpor 
that  we  could  scarcely  recognize  one  another ;  we  marched 
in  gloomy  silence.  The  organ  of  vision  and  the  muscular 
strength  were  weakened  so  that  it  was  difficult  to  proceed, 
and  even  to  maintain  one's  equilibrium.  The  individual 
thus  affected  fell  at  the  feet  of  his  companions,  who  did  not 
turn  their  eyes  to  look  at  him.  Although  I  was  one  of  the 
mo^t  robust  men  in  the  army,  it  was  with  the  greatest  diffi- 
culty that  I  managed  to  reach  Wilna.  On  my  arrival  at 
that  town,  I  had  no  more  strength  or  courage  left  ;  I  was 
ready  to  fall  to  rise  no  more,  like  so  many  other  poor 
wretches  who  had  perished  before  my  eyes.  .  .  .  The  road 
from  Miedzeski  to  Wilna  was  covered  with  corpses.  Death 
in  these  poor  creatures  was  preceded  by  pallor  of  the  face,  a 
sort  of  idiocy,  difficulty  of  speech,  and  by  weakness,  or  even 
a  total  loss,  of  sight.  In  this  condition  some  of  them  marched 
for  a  while,  guided  by  their  comrades  or  friends  ;  muscular 
action  grew  perceptibly  weaker,  the  individuals  staggered  as 
if  they  were  drunk ;  weakness  increased  steadily  until  the 
man  fell — a  certain  sign  of  the  total  extinction  of  life.  .  .  . 
They  were  immediately  struck  by  painful  torpor,  then  passed 
into  a  state  of  lethargic  drowsiness,  and  in  a  few  minutes 
their  burdensomjC  existence  was  over.' 

Similar  cases  were  observed  on  the  ship  Tegethoff,  and 
have  been  described  by  Payer  and  Weyprecht  while  winter- 
ing in  the  ice  at  a  temperature  of  58°  F.  When  the  men 
left  their  cabin  to  go  out,  they  were  sometimes  exposed  to  a 
difference  of  126°  or  130°  F.  ;  but  as  it  was  possible  to  keep 
the  cabin  warm,  they  were  able  to  withstand  these  violent 
changes. 

I  have  told  you,  and  I  repeat,  that  sudden  death  may  be 
produced  without  the  external  temperature  being  extraordin- 
arily low.  It  has  been  observed  even  with  the  thermometer 
3-t  32°,  30°,  or  28°  F.,  when  the  wnnd  is  very  strong.  This  is 
a  very  important  fact  to  know  in  forensic  medicine. 

In  1845,  General  Levasseur,  after  receiving  a  repulse,  led 


204  SUDDEN  DEATH. 


his  troops  to  Setif.  This  is  the  retreat  which  is  known  as 
'  The  retreat  of  Bou  Thaleb  '  ;  it  occupied  forty-eight  hours, 
during  which  the  thermometer  did  not  fall  below  32°  F.  But 
the  wind  blew  with  such  force  that  the  men  could  not  light  a 
fire,  and  consequently  could  not  prepare  their  soup.  Out  of 
2,800  soldiers  commanded  by  General  Levasseur,  208  died  in 
forty-eight  hours,  and  when  the  column  arrived  at  Setif,  521 
entered  the  hospital.  The  never-abating  wind,  together  with 
inanition  and  the  despondency  v/hich  always  attends  retreat, 
had  made  these  soldiers  less  able  to  resist  cold  than  they 
would  have  been  under  other  circumstances. 

The  medico-legal  questions  connected  with  death  from 
cold  are  not  numerous ;  it  is  necessary  to  take  into  account 
the  intensity  of  the  cold,  the  force  of  the  wind,  and  the 
length  of  time  that  the  individual  has  been  exposed  to  their 
influence.  An  adult  resists  cold  tolerably  well,  because  of 
the  size  of  his  body,  provided,  at  any  rate,  that  he  is  not  an 
alcoholic  subject,  and  that  he  does  not  enter  a  wine-shop  or 
tavern  on  the  w^ay.  Alcohol,  which  dilates  the  capillaries, 
promotes  the  action  of  cold.  Here  is  an  instance,  which 
took  place  in  Russia :  The  thermometer  was  about  18°  or 
19°  F.,  and  the  fete  to  celebrate  the  distribution  of  spirit 
licences  was  being  held  in  a  certain  town.  Potemkin  gave 
a  supply  of  alcohol  for  gratuitous  distribution  in  the  square 
of  the  town  ;   1,500  to  1,800  persons  died  of  cold. 

In  the  country,  when  an  individual  is  found  benumbed 
with  cold  or  frozen,  he  is  not  allowed  to  pour  brandy  down 
his  throat,  but  he  is  laid  on  a  manure-heap  or  in  an  oven 
used  for  baking  bread  ;  empiricism  is  thus  in  agreement  with 
the  teachings  of  science,  and  has  long  ago  found  a  means  of 
combating  the  disastrous  effects  of  cold. 

Inanition,  of  course,  aggravates  the  effects  of  cold.  It  is 
a  singular  thing  that  lunatics  are  unaffected  by  it ;  they  do 
not  complain  of  cold,  and  they  resist  it  better  than  their 
attendants. 

New-born  children  are  exposed  to  great  dangers  from 
chills  ;  they  are  not  protected  by  the  mass  of  their  body,  and 
they  generate  only  a  small  amount  of  heat.  They  are  most 
exposed   on   the    occasion  when    they  are    taken    into    the 


MODIFICATIONS  OF  VASCULAR  TENSION.  205 

country  in  what  is  called  the  '  nurse's  convoy.'  When  the 
passengers  alight  from  the  railway  carriage,  after  a  journey 
that  has  lasted  some  hours,  some  poor  little  infant  is  often 
found  to  be  dead  already,  or  else  dying,  and  about  to  finish  his 
days  in  the  vehicle — appropriately  called 'purgatory ' — which 
is  to  take  him  to  the  village  which  was  his  destination.  Some- 
times the  chill  of  which  these  nurslings  die  is  purposely 
contrived.  The  plan  is  very  simple,  and  the  medical  jurist 
will  have  great  difficulty  in  proving  it.  The  door  and  window 
are  both  left  open  ;  the  infant  is  suspended  from  a  nail  in  a 
current  of  air,  and  the  result  is  only  such  as  might  be  fore- 
told. If  the  medical  jurist  intervenes,  he  finds  the  signs  of 
pulmonary  congestion,  with  mucus  and  froth  in  the  bronchi. 

What  conclusions  can  safely  be  drawn  from  such  data  ? 
Chills  are  also  the  most  frequent  causes  of  death  as  a  result 
of  baby-shows. 

With  regard  to  old  people,  the  law  interferes  in  cases  of 
sequestration.  You  know  that  in  country  places  the  father 
and  mother  often  give  their  property  to  their  children,  in 
order  that  the  latter  may  provide  for  themselves,  on  condition 
that  they  shall  be  comfortably  boarded  and  lodged  as  long  as 
they  live.  The  children  are  sometimes  ungrateful  ;  the  old 
father  is  sometimes  half  starved  ;  he  is  consigned  to  a  damp, 
cold  room,  and  dies  of  pulmonary  catarrh.  A  medico-legal 
investigation  is  in  most  cases  fruitless. 


LECTURE  VI. 

SUDDEN  DEATH  DUE  TO  LESIONS  OF  THE  DIGESTIVE 

SYSTEM. 

Gentlemen, —  Lesions  of  the  oesophagus,  stomach  and 
intestines  may  cause  sudden  and  suspicious  death.  Certain 
diseases  of  the  pharynx  may  do  the  same. 

I.  LESIONS  OF  THE  PHARYNX. 

I  shall  perhaps  astonish  you,  Gentlemen,  by  saying  that 
sudden  death  may  supervene  in  the  course  of  simple  pharyn- 
gitis, or  erythematous  sore  throat.  An  autopsy  throws  no 
light  on  these  very  puzzling  cases.  I  do  not  know  of  many 
cases  of  the  kind,  it  is  true,  but  those  which  I  am  able  to 
relate  to  you  are  typical : 

It  is  some  years  since  I  met  with  an  event  of  this  kind. 
I  was  asked  to  attend  a  young  medical  student  who  was 
dresser  to  M.  Cusco ;  he  had  just  had  an  attack  of  syncope. 
As  he  was  suffering  from  a  slight  sore  throat  in  the  evening. 
I  went  to  see  him  again  on  the  following  day  with  M.  Cusco. 
M.  Cusco,  who  was  at  the  time  paying  much  attention  to 
laryngoscopy,  examined  his  pupil's  larynx,  and  found  neither 
oedema  nor  even  redness  there.  The  young  man  had  another 
attack  of  syncope,  but  revived ;  he  had  a  third  during  the 
night,  and  recovered  again.  He  asked  AL  Cusco's  permission 
to  spend  a  little  time  with  his  family,  and  in  a  fortnight 
wrote  to  ask  for  extension  of  leave.  He  caught  a  fresh  chill 
while  he  was  staying  with  his  relatives,  pharyngitis  returned, 
and  he  died  in  an  attack  of  syncope.     This  fact,  which  I 


LESIONS  OF  THE  DIGESTIVE  SYSTEM.  207 

believed  for  a  long  while  to  be  a  solitary  instance,  surprised 
me  much. 

In  1874  I  was  called  in  a  great  hurry  to  see  a  girl  who 
was  suffering  from  a  slight  sore  throat,  and  who,  I  was  told, 
had  had  an  attack  of  syncope.  When  I  arrived,  as  speedily 
as  possible,  she  was  dead. 

Finally,  not  very  long  ago,  I  received  a  pitiful  letter  from 
a  young  provincial  physician,  who  believed  he  was  to  be 
blamed  for  a  fatal  accident  which  had  befallen  one  of  his 
patients,  and  he  begged  for  my  opinion. 

This  physician  had  been  summoned  one  night  to  the 
suburbs  of  the  small  town  where  he  practised  to  attend  a 
girl  who  complained  of  a  sore  throat.  The  throat  was 
somewhat  red ;  there  was  some  gastric  disturbance,  but 
there  were  no  grave  symptoms,  and  considering  the  hour  of 
the  night,  and  the  distance  from  any  druggist,  the  physician 
did  not  insist  on  the  administration  of  an  emetic,  which  he 
intended  to  prescribe  on  the  following  day.  When  he 
returned  the  next  day,  the  girl  was  dead.  I  reassured  my 
fellow-practitioner,  and  replied  that  the  administration  of  an 
emetic  would  not  have  altered  the  situation. 

Simple  sore  throat  may,  therefore,  provide  us  with  a  very 
disagreeable  surprise,  and  as  the  redness  disappears  after 
death,  we  are  not  entitled  to  conclude  that  no  sore  throat 
has  existed  because  no  trace  of  it  is  to  be  found  at  the 
autopsy.  What  is  the  nature  of  these  accidents  ?  In  my 
opinion  it  resembles  laryngeal  spasm,  or  the  inhibition  which 
results  from  a  blow,  although  a  slight  one,  over  the  larynx. 
Remember,  in  this  connexion,  that  case  which  I  have  already 
narrated  to  you  of  the  maid-of-honour,  Mme.  Adelaide,  who 
died  suddenly,  at  the  moment  when  a  Danish  physician  was 
applying  a  drop  of  ammonia  to  her  pharynx. 

Closely  allied  to  these  pharyngeal  phenomena,  which  we 
must  ascribe  to  spasm  or  inhibition  until  we  get  a  better 
classification,  there  are  others  in  which  sudden  death  is  the 
effect  of  material  causes. 

When  an  individual  swallows  hard  and  compact  sub- 
stances, or  when  he  eats  gluttcnously,  and  the  food  which 
he  stuffs  into   his  throat  blocks  the  entrance  of  his  larynx. 


2o8  SUDDEN  DEATH. 


he  dies  suddenly,  choked.  Accidents  of  this  sort  are  not 
uncommon  among  general  paralytics,  and  I  ask  you  to  bear 
this  liability  in  mind. 

II.  LESIONS  OF  THE  CESOPHAGUS. 

I  come  now  to  lesions  of  the  oesophagus.  We  meet  with 
cases  here,  Gentlemen,  which  are  often  singular,  sometimes 
inexplicable,  and  which  may  give  rise  to  suspicion  of  poison- 
ing. It  was  with  this  in  view  that  M.  Letulle  reported  two 
cases  of  sudden  death  due  to  dilatation  of  the  oesophagus, 
with  small  superficial  ulcerations  in  one  case,  but  which 
were  absent  in  the  other.  The  autopsy  did  not  reveal  the 
cause  of  the  dilatation  in  either  of  them.  We  know,  besides, 
that  in  stricture  of  the  oesophagus  there  may  be  an  accumu- 
lation of  food  in  the  pouch  above  the  stricture,  which  may 
cause  sudden  death  by  pressure. 

At  this  very  moment  a  great  stir  is  being  made  in  some 
of  the  newspapers  about  the  supposed  poisoning  of  the 
Comte  de  Chambord.  You  know  that,  when  the  Comte  de 
Chambord  was  taken  ill,  several  eminent  physicians,  includ- 
ing Vulpian,  were  summoned  to  Frohsdorf  The  physicians 
who  met  at  the  patient's  bedside  agreed  in  the  diagnosis  of 
cancer  of  the  stomach.  After  a  temporary  improvement, 
the  patient's  condition  grew  worse  and  he  died.  Post-inortein, 
no  cancer  was  found  at  all ;  only  superficial  ulcerations,  with 
a  few  deeper  ones,  were  found  in  the  oesophagus.  Vulpian, 
with  characteristic  honesty,  did  not  hesitate  to  declare,  not 
only  that  he  had  made  a  mistake  in  pronouncing  that  the  case 
was  one  of  cancer,  but  also  that  he  could  not  state  what  was 
the  cause  of  the  ulceration  of  the  oesophagus.  By  that  time 
rumours  of  poisoning  were  going  about;  then  no  more  was 
heard  about  it.  For  some  weeks  this  rumour  has  been 
revived  again,  and  it  is  openly  stated  in  certain  circles  that 
the  Comte  de  Chambord  was  poisoned.  None  of  the 
persons  who  make  this  assertion  could  state,  any  more  than 
I  could,  what  poison  is  capable  of  producing  these  lesions. 

Gentlemen,  lesions  that  we  did  not  expect  to  find  are 
often  met  with  in  making  autopsies  ;  lesions  are  also  met 


LESIONS  OF  THE  DIGESTIVE  SYSTEM.  209 

with  which  are  not  described  in  any  nosological  scheme, 
lesions  which  we  cannot  classify  at  all.  These  are  matters 
which  surprise  us,  I  admit,  but  they  do  not  justify  us  in 
expressing  a  suspicion  of  poisoning.  It  is  certain  that  when 
this  happens  in  the  case  of  a  person  of  princely  rank,  or  of 
a  political  notability,  the  imagination  is  prone  to  exaggerate 
everything,  and  to  find  something  extraordinary  in  what 
would  only  have  been  looked  on  as  natural  in  a  member  of 
the  middle  class.  If  you  survey  the  histor)^  of  France,  your 
attention  will  often  be  arrested  by  similar  cases,  and  a  great 
number  of  princes  and  princesses,  who  were  believed  to  have 
been  poisoned,  really  died  a  natural  death. 

III.  LESIONS  OF  THE  STOMACH. 

Before  entering  upon  the  study  of  the  lesions  of  the 
stomach  which  may  cause  sudden  death,  let  us  first  settle 
two  incidental  questions — sudden  death  from  indigestion, 
and  death  in  dyspeptic  coma. 

Can  a  person  die  suddenly  from  indigestion  ?  (Notice  that 
I  am  not  speaking  here  of  children ;  I  shall  deal  with  them 
later  on).  All  authors  reply  in  the  affirmative.  Well, 
Gentlemen,  I  have  read  all  the  cases  which  they  have 
recorded,  but  I  have  not  met  with  a  single  case  in  which 
pre-existing  lesions  in  other  organs  than  the  stomach  were 
not  sufficient  to  account  for  death ;  in  most  cases  the 
patient  had  some  renal  affection,  or  was  convalescent  from 
typhoid  fever. 

Such  was  the  case  of  the  lad  which  Dr.  Martel*  has 
reported  :  the  boy  was  convalescent  from  a  mild  attack  of 
typhoid  fever,  and  was  allowed  to  walk  about  the  ward  as  he 
pleased,  when  one  day,  after  breakfast,  he  had  an  attack  of 
syncope,  and  died  so  rapidly  that  he  was  dead  before  the 
arrival  of  the  house-physician,  though  the  latter  had  been 
summoned  at  once.  An  autopsy  was  made  ;  all  the  organs 
were  healthy,  but  the  stomach  was  distended  by  a  mass  of 
haricot  beans  not  yet  acted  upon  by  the  gastric  juice.  This 
lad,  who  had  been  subjected  to  a  strict  regimen  during  his 
*  Martel,  Caz.  hebdofn.,  1877,  P-  605. 

14 


SUDDEN  DEATH. 


fever,  acquired  an  exaggerated  appetite,  as  convalescents 
commonly  do  ;  he  had  obtained  an  extra  supply  of  this 
indigestible  food  from  his  comrades,  and  had  swallowed  it 
hastily  to  avoid  being  detected. 

If  this  lad  had  eaten  these  beans  in  his  ordinary  state  of 
health,  he  might  have  had  an  attack  of  indigestion,  but  he 
would  not  have  died.  Tardieu  only  quotes  one  case,  and  it 
is  hardly  conclusive  : 

An  individual,  who  was,  as  the  report  says,  somewhat  out 
of  health,  went  to  a  druggist,  who  gave  him  four  purgative 
pills.  He  swallowed  only  two  of  these  before  retiring  to 
rest ;  in  the  night  he  was  seized  with  vomiting  and  died. 
The  druggist  was  accused  of  having  poisoned  his  customer. 
The  two  remaining  pills  were  found  and  submitted  to 
analysis,  but  they  contained  no  suspicious  substance.  The 
autopsy  revealed  no  organic  disease. 

The  druggist  who  sold  the  pills  was  accused  of  having 
poisoned  the  patient,  but  an  analysis  of  two  pills  that 
remained  disclosed  nothing  suspicious.  For  my  own  part,  I 
believe  that  indigestion  will  in  the  very  near  future  be  erased 
from  the  list  of  causes  of  sudden  death. 

Dyspeptic  coma  has  been  studied  in  Germany  especially  ;  I 
have  only  met  with  two  cases,  neither  of  which  was  fatal. 
It  is  analogous  to  diabetic  coma ;  but  there  is  no  sugar  in 
the  urine.  It  has  been  profoundly  studied  by  Kussmaul, 
and  hence  has  received  the  name  of  '  Kussmaul's  group 
of  symptoms.'  The  name  connotes  a  group  of  symptoms 
which  I  w^ill  describe  to  you  briefly.  Suppose  that  an 
individual  in  good  health,  who  may  or  may  not  have  suffered 
from  dyspepsia  formerly,  is  suddenly  seized  with  somnolence, 
at  first  slight,  but  rapidly  deepening  into  coma,  and  with  a 
peculiar  form  of  dyspnoea  characterized  by  deep  and  regular, 
but  often  accelerated,  respiratory  movements-  The  tempera- 
ture is  more  often  lowered  than  raised,  and  the  breath  has  a 
characteristic  odour  like  that  of  apples  or  over-ripe  fruit,  and 
the  urine  is  reddened  by  the  addition  of  perchloride  of  iron. 

It  has  been  thought  that  these  phenomena  are  due  to 
auto-intoxication  by  acetone,  liberated  by  intestinal  fermen- 
tation.    Acetone  actually  has   an    odour    like   that    of  ripe 


LESIONS  OF  THE  DIGESTIVE  SYSTEM.  211 

fruit,  and  the  addition  of  perchloride  of  iron  produces  a  red 
colour  when  it  is  present  in  the  urine. 

But  Senator,  Riess,  and  Litten  have  detected  acetone 
when  there  has  been  no  coma  ;  they  have,  moreover,  insisted 
on  the  fact  that  Kussmaul's  group  of  symptoms  is  met  with 
in  the  course  of  various  diseases,  such  as  pernicious 
anasmia,  diseases  of  the  hver  and  kidneys,  chronic  catarrh  of 
the  bladder,  certain  eruptive  diseases,  etc. 

We  ought,  therefore,  to  ask  ourselves  whether  it  is  not 
one  of  these  diseases  which  is  the  cause  of  death,  rather 
than  dyspeptic  coma,  which  v/e  will  regard,  if  you  please, 
merely  as  an  exceptional  occurrence. 

We  ought  to  place  by  the  side  of  Kussmaul's  disease  the 
sulphuretted  hydrogen  dyspepsia  of  children,  which  has 
been  described  by  Senator,  Cantani  and  Stefano.  I  have 
no  personal  experience  of  it. 

Simple  ulcer  of  the  stomach  is  a  very  common  cause  of 
sudden  death.  The  round  ulcer,  which  has  only  been  well 
known  since  Cruveilhier's  time,*  is  not  a  disease  that  has 
only  appeared  in  modern  times. 

Madame,  sister-in-law  to  Louis  XIV.,  whose  funerai 
oration  was  delivered  by  Bossuet,  appears  to  have  died  of 
simple  ulcer  of  the  stomach.  The  symptoms  which  her 
disease  presented,  its  sudden  gravity  and  tragical  ending, 
immediately  gave  rise  in  the  minds  of  contemporaries  to 
the  idea  of  poisoning. 

Nowadays  we  are  familiar  with  the  characters  of  ulcer 
of  the  stomach,  and  it  would  seem  to  be  difficult  to  make 
a  blunder. 

However,  one  of  the  first  medico-legal  cases  with  which 
I  had  to  do  was  one  of  this  kind.  Mme.  Lerondeau,  a 
woman  living  in  a  suburb  of  Versailles,  was  accused  of 
having  poisoned  her  husband.  He  had  complained  to 
several  of  his  neighbours  of  not  feeling  well  one  morning, 
and  died  the  same  day,  after  taking  some  sorrel  soup 
which  his  wife  had  prepared  for  him.  I  do  not  know 
whether  the  husband  and  wife  had  been  living  on  bad 
terms  together,  but  the  fact  is  that  the  law  intervened ; 
*  Cruveilhier,  'Anatomic  pathologique.'     Paris,  1830-32. 


SUDDEN  DEATH. 


the  woman  was  arrested,  and  a  post-mortem  examination 
was  ordered.  The  analytical  chemist  found  a  small  quantity 
of  oxalic  acid  in  the  stomach;  the  medical  jurist  discovered 
on  the  mucous  membrane  of  the  stomach,  and  minutely 
described,  six  small  ulcers  near  the  pylorus  He  did  not 
think  that  these  were  simple  gastric  ulcers,  but  asserted 
that  they  were  caused  by  oxalic  acid  that  had  been  put 
into  the  soup,  and  Mme.  Lerondeau  was  sentenced  to  im- 
prisonment with  hard  labour.  Owing  to  a  flaw  in  the 
proceedings,  the  sentence  was  annulled,  and  the  case  was 
transferred  from  the  Court  of  Versailles  to  that  of  Paris. 
Mme.  Lerondeau's  counsel  applied  to  Wurtz,  Vulpian,  and 
Bergeron.  Vulpian  examined  the  specimen,  and  found  that 
the  lesions  had  all  the  appearances  of  simple  gastric  ulcer. 
Wurtz  has  shown,  in  a  remarkable  memoir,  that  when  the 
mucous  membrane  is  in  a  catarrhal  state,  the  digestion 
even  of  a  piece  of  bread  gives  rise  to  the  formation  of 
oxalic  acid,  even  to  a  more  considerable  amount  than  that 
found  by  the  chemist  at  Versailles  in  M.  Lerondeau's 
stomach.  The  Attorney-General  abandoned  the  prosecution. 
It  is  not  very  difficult.  Gentlemen,  when  we  discover  an 
ulcer  of  the  stomach,  to  determine  whether  it  has  been 
caused  by  some  caustic  substance  or  by  natural  inflam- 
matory processes.  In  the  simple  ulcer  you  will  always 
find  the  characteristic  projecting  margin  and  smooth 
base,  which  cannot  deceive  you.  When  an  individual  has 
swallowed  sulphuric  or  hydrochloric  acid,  there  are  erosions, 
perforations,  and  lesions  of  all  kinds. 

A  simple,  round  gastric  ulcer  may  develop  in  a  latent 
manner,  without  producing  any  marked  functional  dis- 
turbance. It  can,  therefore,  easily  be  understood  how  a 
suspicion  of  poisoning  may  arise  in  the  mind  of  some 
relative  or  friend  of  the  deceased.  This  suspicion  is  evinced 
more  frequently — I  will  even  say  that  it  is  constant — when  a 
person  dies  of  perforation  of  the  stomach  with  symptoms  of 
peritonitis. 

It  might  be  thought  that  an  individual  in  whom  perfora- 
tion has  suddenly  occurred  ought  always  to  present  the 
characteristic  signs  of  peritonitis,  but  it  is  not  so  ;  he  may 


LESIONS  OF  THE  DIGESTIVE  SYSTEM.  213 

become    collapsed,    and    present    symptoms   like   those    of 
cholera. 

Leudet  of  Rouen*  has  related  the  following  case :  While 
he  was  house-physician  at  the  Hotel-Dieu,  a  man  walked 
abruptly  out  of  a  public-house  facing  the  hospital,  holding 
his  hand  to  his  abdomen,  suffering  acute  pain,  and  exclaim- 
ing :  'They  have  poisoned  me!'  The  man  was  taken  to 
the  Hotel-Dieu,  while  the  crowd,  believing  what  he  said, 
proceeded  to  sack  the  public-house.  The  man  died.  Leudet 
made  an  autopsy,  and  discovered  perforation  of  the  stomach 
by  a  simple  ulcer,  and  commencing  peritonitis. 

When  the  simple  ulcer  is  undergoing  cicatrization,  and 
the  patient  is  getting  better,  the  intolerable  pain  after  eat- 
ing having  disappeared,  and  a  strict  milk  diet  being  no 
longer  persisted  in,  he  is  sometimes  tempted  to  eat  more 
than  is  good  for  him,  and  the  consequences  may  be  most 
disastrous. 

While  I  was  Aran's  house-physician  at  the  St.  Antoine 
Hospital,  a  man  was  under  his  care  suffering  from  simple 
ulcer  of  the  stomach,  which  was  healing,  and  he  had 
abandoned  a  strict  milk  diet.  It  was  spring-time,  and  the 
man  was  walking  about  the  hospital  yard.  He  went  to  the 
porter's  lodge,  bought  an  apple-tart,  and  ate  it  in  the  yard. 
He  was  immediately  seized  with  vertigo,  fell  down,  was 
carried  indoors,  was  put  to  bed,  and  soon  died.  At  the 
autopsy  the  cicatrix  was  found  to  be  torn,  and  the  organ 
was  distended  with  gases  which  had  penetrated  beneath  the 
mucous  membrane  of  the  stomach,  so  that  the  walls  seemed 
to  be  inflated. 

Since  the  time  of  Hunter  and  Cruveilhier,  post-mortem 
ulceration  of  the  stomach  has  been  recognized  as  a  fact ;  it 
is  attributed  to  the  action  of  gastric  juice  upon  a  portion 
of  the  wall  of  the  stomach  which  has  lost  its  epithelium  or 
undergone  some  other  lesion.  All  that  I  know  of  these 
ulcers  is  obtained  from  the  writings  of  authors  ;  I  have  never 
had  any  opportunity  of  seeing  them,  but  I  have  twice  seen 
a  post-mortem  ulceration  under  similar  conditions,  as  a  result 
of  poisoning  by  a  non-caustic  substance.  In  both  cases  the 
*  Leudet,  '  Clinique  medicale.'     Paris,  1874. 


214  SUDDEN  DEATH. 


poison  was  strychnine  ;  one  was  a  case  of  suicide,  the  other 
of  accidental  poisoning. 

Let  us  take  this  case  :  A  boy  went  to  a  druggist  to  ask  for 
poison  wherewith  to  get  rid  of  his  cat,  as  he  was  tired  of  the 
animal.  The  druggist,  whom  it  was  impossible  to  identify, 
handed  him  a  packet  of  strychnine.  The  boy  went  home, 
altered  his  mind,  and  deposited  the  poison  in  his  desk. 
Then  he  thought  he  would  like  to  see  what  the  powder 
tasted  like,  so  he  moistened  his  finger,  dipped  it  in  the 
powder,  and  tasted  it,  though  he  spat  most  of  it  out  again 
(he  was  able  to  state  thisj,  and  he  died  in  well-marked 
strychnine  convulsions.  Post-mortem,  I  found  the  stomach 
small,  containing  about  2  oz.  of  blackish  liquid ;  in  the 
fundus  there  was  a  circular  perforation  it  inches  in  diameter, 
and  at  a  distance  of  i  inch  from  this  was  another  perforation 
about  +  inch  in  diameter.  The  mucous  membrane  seemed 
to  have  undergone  digestion.     The  spleen  was  a  soft  pulp. 

Experiments  on  animals  show  that  the  introduction  of  a 
certain  quantity  of  strychnine  into  the  stomach  considerably 
increases  the  secretion  of  gastric  juice ;  perhaps  that  is  the 
way  (I  only  offer  the  suggestion)  that  strychnine  acts  in 
certain  affections  of  the  stomach. 

When  you  are  making  an  autops}^,  and  find  a  perforation 
of  the  stomach,  you  will  have  to  make  a  differential  diagnosis 
between  simple  gastric  ulcer,  poisoning,  and  the  ingestion  of 
some  caustic  substance. 

I  will  quote  one  other  case  to  you  before  ending  the 
account  of  sudden  death  from  diseases  of  the  stomach.  A 
Paris  physician,  who  was  well  known  in  the  theatrical  world, 
had  suffered  for  a  long  time  from  dyspepsia.  He  married  a 
very  pretty  and  elegant  young  wife  ;  he  was  also  accustomed 
to  administer  morphine  injections  to  himself.  The  rumour 
went  about  among  his  friends  and  the  public  that  his  wife 
would  be  only  too  pleased  to  be  rid  of  her  husband.  He 
died.  His  friends  insisted  on  a  medico-legal  post-mortem 
examination,  but  they  were  not  satisfied  with  the  result  of  it. 
They  then  examined  the  numerous  volumes  in  which  the 
deceased  had  written  day  by  day  for  more  than  twenty  years 
his  impressions  and  details  of  his  sufferings.     Fortunately 


LESIONS  OF  THE  DIGESTIVE  SYSTEM.  215 

for  his  young  widow,  her  husband's  notes  and  the  opinions 
of  the  physicians  whom  he  had  consulted  agreed  with  the 
results  of  the  autopsy,  and  the  proceedings  were  stayed. 
The  autopsy  had  brought  to  light  an  enormous  dilatation  of 
the  stomach,  the  larger  curvature  measuring  30  inches,  the 
smaller  ig  inches  ;  the  food  could  not  easily  pass  out  of  the 
stomach,  for  the  pylorus,  which  was  situated  in  the  right 
iliac  fossa,  was  connected  to  the  rest  of  the  intestine  by 
means  of  the  duodenum,  which  was  curved  like  a  swan's 
neck.  There  was  a  formidable  accumulation  of  liquid  con- 
taining detritus  of  food  in  the  stomach  ;  the  colon  was  filled 
with  scybala  as  large  as  one's  fist. 

IV.    LESIONS   OF   THE   INTESTINES. 

Medico-legal  intervention  is  much  more  frequent  in  simple 
ulcerations  of  the  duodenum,  M.  Aloncle*  has  collected  39 
cases.  Since  then  M.  Bucquoy  has  published  a  certain 
number,  and  the  total  number  of  cases  on  record  amounts 
to  a  hundred. 

A  distinguishing  feature  of  simple  ulcer  of  the  duodenum 
is  that  its  existence  is  quite  unknown  both  to  the  patient  and 
to  those  around  him.  In  ulcer  of  the  stomach  there  are 
pain,  vomiting  and  hgemorrhage  ;  ulcer  of  the  duodenum 
gives  rise  to  no  symptoms.  Moreover,  sudden  death,  in  the 
medico-legal  sense,  is  comparatively  more  frequent  in  the 
latter  than  in  the  former. 

A  well-built  youth,  about  20  years  of  age,  was  brought  to 
the  Pitie  Hospital.  He  complained  of  acute  pain,  and  kept 
his  hands  pressed  on  his  abdomen  ;  he  had  been  very  well 
during  the  day,  but  at  7  p.m.  he  was  seized  with  atrocious 
pain  in  the  abdomen,  seemingly  situated  between  the 
stomach  and  liver.  He  soon  became  collapsed,  and  died  at 
5  a.m.  He  presented  symptoms  like  those  of  cholera — 
aphonia,  suppression  of  urine,  etc.  The  autopsy  showed  that 
this  young  man  had  a  simple  ulcer  of  the  duodenum  ;  it 
was  evidently  of  long  standing,  being  surrounded  by  a  rim 
like   that  of  a  simple   round   ulcer  of  the    stomach.      The 

*  Aloncle, '  De  I'Ulcere  perforant  du  Duodenum.'    These  de  Paris,  1883. 


2i6  SUDDEN  DEATH. 


intestine  was  perforated,  and  food  had  entered  the  peritoneal 
cavity  ;  the  peritoneal  cavity  contained  2h  pints  of  yellowish 
fluid. 

Ulcers  of  the  duodenum  are  situated  in  the  first  part 
of  that  segment  of  the  bowel,  and  by  preference  on  its  free 
surface. 

I  know  of  only  one  case  of  perforating  ulcer  of  the 
jejunum. 

Intestinal  ulceration  may  be  caused  by  dysentery,  tuber- 
culosis, cancer,  or  typhoid  fever.  Medico-legal  intervention 
is  sometimes  demanded  by  the  relatives  of  the  deceased  in 
such  cases. 

I  remember  the  following  case  :  A  girl  belonging  to  a  very 
honourable  family  was  attacked  with  typhoid  fever,  and 
stated  in  her  delirium  that  she  had  been  violated,  giving  full 
details  and  quoting  names.  She  died,  and  her  parents, 
recollecting  the  delirious  statements  made  by  their  daughter, 
insisted  on  an  autopsy  being  made.  The  girl  had  ulceration 
of  the  ileum,  and  was  a  virgin.  Whether  or  not  an  attempt 
on  her  chastity  had  been  made,  I  do  not  know,  but  at  any 
rate  the  act  of  violation  had  not  been  completed. 

All  these  ulcers  may  give  rise  to  intestinal  haemorrhage, 
which  may  produce  syncope.  Death  may  result  from  it, 
and  we  ought  always  to  bear  the  possibility  in  mind. 
M.  Lancereaux  has,  within  the  last  few  years,  thrown  light 
upon  a  subject  that  was  already  known,  but  which  had  been 
imperfectly  studied  before ;  I  refer  to  embolism  of  the 
mesenteric  artery,  which  may  give  rise  to  intestinal  ulcera- 
tion and  haemorrhage.  Finally,  we  sometimes  meet  with 
persons  who  have  died  of  intestinal  haemorrhage,  although 
it  is  impossible  to  discover  the  vessel  that  has  given  way. 
This  fact  has  been  established  by  Gendrin  and  Trousseau. 

Much  importance  has  lately  been  attached  to  a  special 
form  of  ulceration  which  takes  place  in  the  vermiform 
appendix.  This  perforation  is  rapidly  followed  by  grave 
symptoms,  which  remind  one  of  those  of  cholera,  and  are 
more  like  those  of  poisoning  than  those  of  peritonitis  ;  there 
are  abdominal  distension  and  vomiting,  and  the  surface 
becomes  cold.     Reginald  Fitz  was  the  first  to  describe  this 


LESIONS  OF  THE   DIGESTIVE  SYSTEM.  217 


disease  ;  it  is  important  for  the  practical  physician  as  well 
as  for  the  medical  jurist  to  know  of  it. 

Never  in  your  practice  pronounce  the  word  '  poisoning,' 
unless  you  are  sure  of  your  diagnosis  ;  if  it  has  once 
escaped  your  lips,  and  reached  the  ears  of  the  patient's 
relatives,  they  will  not  be  able  to  think  of  anything  else  ! 
Before  uttering  a  word  of  suspicion,  think  over  all  the 
phenomena  of  perforation  which  I  have  briefly  described  to 
you  ;  it  is  a  diagnosis  which  you  will  have  to  make,  though 
it  is  not  always  very  easy  to  establish. 

Hindrance  to  the  passage  of  the  contents  of  the  intestine  may 
be  of  long  standing  or  may  develop  abruptly.  In  both  cases 
it  m^ay  give  rise  to  sudden  and  suspicious  death.  When  it 
is  abrupt,  there  is  internal  strangulation.  A  small  hernia, 
unknown  to  the  subject  of  it,  may  be  strangulated  at  the 
moment  of  its  formation  ;  its  existence  can  only  be  proved 
post-mortem,  because  liquids  have  been  able  to  pass  along  the 
intestine  during  the  lifetime  of  the  patient ;  strangulation 
has  not  been  complete ;  the  symptoms  presented  by  the 
patient — diarrhoea,  vomiting,  and  coldness  of  the  surface 
— have  led  to  the  belief  that  the  case  is  one  of  poisoning. 
Such  cases  happen  by  the  thousand. 

In  simple  intestinal  obstruction  medico-legal  intervention  is 
sometimes  required.     Let  me  give  you  an  example  : 

Towards  the  end  of  the  Empire,  an  old  lady  was  seized 
with  uncontrollable  vomiting.  As  she  had  occupied  a  con- 
spicuous social  position  and  had  been  intimately  connected 
with  one  of  the  Bonaparte  family,  it  was  thought  that  she 
had  been  poisoned.  The  physician  who  attended  her 
advised  a  consultation.  At  the  time  when  the  consultation 
was  to  take  place,  the  old  lady  was  sitting  on  her  zinc 
toilet-pail,  and  suddenly  a  curious  noise  was  heard,  the 
nature  of  which  was  not  evident  at  the  moment ;  she  had 
just  passed  an  enormous  gall-stone,  which  is  now  exhibited 
in  Dupuytren's  museum  ;  this  calculus  had  blocked  the 
intestine.  Naturally  all  suspicion  of  poisoning  was  dispelled  ; 
the  lady  recovered  and  returned  to  America,  where  she  died 
recently  more  than  80  years  of  age. 

Forensic  medicine  may  also  have  to  deal  with   cases  of 


SUDDEN  DEATH. 


simple  constipation ;  in  one  case  nearly  30  oz.  of  faeces  was 
found  in  the  intestine.  M.  Socquet  has  removed  from 
the  large  intestine  lyh  lbs.  of  fsecal  matter. 

A  great  inventor,  who  had  amassed  a  large  fortune,  but 
whose  name  I  shall  not  mention,  habitually  suffered  from 
obstinate  constipation  ;  he  soothed  his  pain  with  chloroform. 

One  day  he  received  a  visit  from  two  friends  who  were  not 
so  well  off,  and  after  their  departure  he  was  found  dead  on 
the  sofa  ;  his  brother,  with  whom  he  had  not  lived  on  the 
best  of  terms,  suspected  that  he  had  been  murdered  by 
these  friends  ;  the  bottle  of  chloroform  and  a  folded  cloth 
had  been  found  by  the  side  of  the  body.  The  law 
intervened,  and  an  autopsy  was  ordered.  I  found  the 
intestine  loaded  with  very  hard  f^ces.  The  autopsy  could 
not  reveal  to  us  how  he  came  by  his  death.  Whether  he 
had  put  himself  to  sleep  for  ever  by  means  of  chloroform, 
or  whether  he  had  been  put  to  sleep  by  his  friends,  I  cannot 
say  ;  but  it  is  always  a  difficult  matter  to  send  a  person  to 
sleep  by  means  of  chloroform  if  he  does  not  wish  to  be 
anaesthetized.  Before  speaking  to  you  of  the  curious 
phenomena  and  complications  which  long-continued  consti- 
pation sometimes  produces,  allow  me  to  point  out  to  you 
the  singular  fact  that  malformations  of  the  anus  may  give 
rise  to  sudden  death.  A  little  girl,  8  years  of  age,  died  with 
symptoms  of  poisoning.  The  body  was  sent  to  the  Morgue 
{or  post-mortem  examination.  The  child  had  an  imperforate 
anus  ;  defgecation  had  been  performed  by  means  of  a  small 
fistulous  communication  between  the  rectum  and  vagina,  a 
little  below  the  hymen  ;  this  fistula  had  been  blocked  by 
hard  faeces  ;  an  enormous  accumulation  had  formed  in  the 
rectum,  which  measured  nearly  5  inches  in  diameter.  There 
was  also  arrest  of  development  of  the  uterus.  This  little 
girl  had  lived  up  to  that  age  without  any  of  the  family  sus- 
pecting that  her  bowels  were  not  relieved  in  the  usual 
manner.  She  died  of  intestinal  obstruction,  the  symptoms 
of  which  were  actually  taken  for  those  of  poisoning. 

These  cases  of  death  due  to  intestinal  mischief  are  very 
interesting,  and  they  are  closely  connected  with  certain 
pathological   problems    that    are    now   receiving    attention. 


LESIONS  OF  THE  DIGESTIVE  SYSTEM.  219 

M  Vibert  has  related  the  following-  case,  which  is  of  great 
medico-legal  interest  because  of  the  situation  occupied  by 
the  victim,  and  because  of  the  disputes  which  might  arise 
after  his  death  as  to  the  payment  of  a  claim  for  life 
assurance  : 

A  young  medical  man,  aged  23,  who  practised  in  the 
suburbs  of  Paris,  went  to  lunch  one  day  at  his  brother's 
house  in  Paris  ;  he  was  in  the  habit  of  taking  injections  of 
morphine;  in  the  morning  he  was  indisposed  owing  to  an 
attack  of  abdominal  pain  and  diarrhoea  ;  he  was  unable  to 
eat  any  luncheon,  and,  as  his  suffermgs  increased,  he  de- 
termined to  return  home  ;  he  died  in  the  water-closet  used 
by  the  station-master,  on  his  arrival  at  the  station  where  he 
intended  to  alight.  As  Dr.  X.'s  brother  knew  that  Dr.  X. 
had  insured  his  life,  he  went  to  the  public  prosecutor  and 
stated  to  him  very  straightforwardly  that  he  had  been  asked 
whether  his  brother's  death  might  not  be  due  to  some 
unforeseen  cause,  viz.,  suicide  by  an  over-dose  of  morphine. 
All  the  inhabitants  of  the  little  town  where  Dr.  X.  practised 
were  convinced  that  suicide  had  taken  place. 

In  case  an  autopsy  confirmed  this  supposition,  M.  X. 
determined  to  renounce  his  claim  upon  the  insurance  office. 
A  medico-legal  autopsy  was  performed  by  M.  Vibert,  and  it 
was  ascertained  that  there  was  a  tubular  stricture  of  the 
descending  colon  commencing  a  little  way  above  the  sigmoid 
fle.'cure,  and  7  inches  in  length  ;  the  wall  of  the  stricture 
was  indurated  and  thickened,  and  presented  a  layer  of  dense 
fibrous  tissue  about  tt-V  inch  in  thickness  beneath  the  mucous 
membrane  ;  the  intestine  was  somewhat  dilated  above  the 
stricture,  and  there  was  a  small  quantity  of  fseces  there. 
M.  Vibert  concluded  that  death  was  due  to  natural  causes, 
there  being  no  evidence  of  the  presence  of  any  poison. 

Since  then  we  have  made  four  autopsies  of  the  same  kind 
at  the  Morgue.  What  is  the  cause  of  death  under  such 
conditions  ?  It  is  identical  with  that  which  I  previously 
described  to  you  under  the  title  of  dyspeptic  coma.  M. 
Bouchard  has  proved  the  existence  of  ptomaines  in  faeces, 
and  in  all  such  cases  special  forms  of  fermentation  may  lead 
to  auto-intoxication,  as  in  this  case.     The  anomalous  feature 


SUDDEN  DEATH. 


of  these  cases  of  poisoning  is  that  they  occur  in  some 
instances,  but  are  absent  in  others.  All  these  novel  facts  are 
of  great  interest  to  the  medical  jurist,  and  he  ought  to  bear 
them  in  mind  when  he  is  conducting  his  investigations. 

To  what  cause  should  these  strictures  be  assigned  ?  As  a 
general  rule,  when  inquiries  are  made  of  the  relatives  and 
friends  of  the  deceased,  and  information  is  obtained  as  to 
the  previous  history,  the  disease  can  be  traced  to  a  neglected 
attack  of  dysentery  ;  cicatrices  result  which  steadily  contract. 

V.  LESIONS  OF  THE  LIVER. 

I  come  now  to  the  consideration  of  those  lesions  of  the 
liver  which  may  occasion  sudden  and  suspicious  death. 
These,  Gentlemen,  include  a  certain  number  of  special 
cases  ;  but  you  will  be  of  the  same  opinion  as  myself  when 
you  listen  to  an  enumeration  of  all  the  diseases  of  the  liver  ; 
and  you  will  agree  that  any  one  of  them  may  lead  to  sudden 
death  under  conditions  which  would  suggest  to  one's  mind 
the  possibility  of  poisoning. 

Take  malignant  jaundice,  for  example  ;  you  know  its 
characters,  and  are  well  aware  of  the  yellow  colour  which 
rapidly  invades  the  face  and  the  whole  body  of  a  person  who 
seemed  well  previously. 

To  my  knowledge,  the  law  has  stepped  in  in  two  fatal 
cases  because  phosphorus -poisoning  was  suspected,  and 
those  individuals  were  prosecuted  to  whose  advantage  it 
was  for  the  death  to  take  place.  In  another  instance, 
where  there  also  was  malignant  jaundice,  the  individual 
who  died  suddenly  had  been  taking  part  in  a  discussion 
shortly  before.  His  neighbours,  who  had  noticed  that  his 
skin  had  become  yellow  in  a  very  short  time,  spread  the 
report  that  his  death  was  due  to  a  violent  paroxysm  of 
anger  to  which  he  had  been  provoked,  and  that  bile  had 
become  mixed  with  his  blood.  As  there  had  been  a  dis- 
pute, the  officers  of  the  court  took  the  matter  up,  thinking 
that  the  deceased  had  perhaps  received  blows  which  would 
occasion  death.  The  man  was  found  to  have  acute  atrophy 
of  the  liver,  which  was  quite  sufficient  to  cause  jaundice 
and  account  for  death. 


LESIONS  OF  THE  DIGESTIVE  SYSTEM.  221 

Finally,  Gentlemen,  I  shall  give  you  the  particulars  of 
a  very  interesting  medicolegal  autopsy,  for  the  case  on 
which  this  inquest  was  held  gave  rise  also  to  an  accusa- 
tion of  attempt  to  procure  abortion.  The  case  was  that  of 
a  female  of  35  to  40  years  of  age,  who  was  a  servant  to  a 
medical  man.  She  suffered  from  atrophic  cirrhosis  of  the 
Hver,  and  had  become  debilitated  in  consequence  of  the 
disease.  Her  abdomen  grew  large,  and  this  was  noticed 
by  her  neighbours.  She  was  seized  with  syncope  one  even- 
ing, and  died  the  same  night.  As  she  had  had  epistaxis 
at  the  moment  of  syncope,  blood  was  found  on  her  sheets, 
pillow,  and  chemise.  The  porter  of  the  house  at  once 
accused  the  medical  man  of  attempting  to  procure  abortion 
on  his  servant.  The  body  was  carried  to  the  Morgue,  and 
I  made  an  autopsy.  The  woman  was  not  pregnant,  but 
she  had  eighteen  or  twenty  pints  of  fluid  in  the  peritoneal 
cavity ;  her  liver  presented  the  typical  characters  of  cir- 
rhosis. 

Sudden  death  due  to  gall-stones  is  a  rare  event.  Portal* 
quotes  two  cases.  Dr.  Durand-Fardel  and  Curry  each 
record  one.  Charcoti"  speaks  of  syncope  sometimes  occur- 
ring in  the  course  of  biliary  colic. 

I  myself  can  relate  to  you  the  following  case  :  A  young 
woman,  25  or  30  years  of  age,  active,  and  of  good  con- 
stitution, forewoman  in  a  feather  manufactory  in  the  Rue 
du  Caire,  had  an  appointment  at  Lagny.  As  she  was 
afraid  of  missing  the  train,  she  ran  to  the  Eastern  Railway 
station  ;  but  when  she  reached  the  Place  de  Strasbourg 
she  found  that  she  had  several  minutes  to  spare,  and  went 
into  a  cafe,  where  she  drank  some  currant  syrup  with 
seltzer-water,  and  having  paid  for  it,  she  took  her  ticket 
and  entered  the  carriage.  The  train  had  only  just  started, 
when  she  was  seized  with  horribly  painful  colic,  and  said 
to  her  fellow-travellers  in  the  compartment  :  '  I  have  been 
poisoned  in  the  cafe  ;  I  do  not  know  what  it  was  that  I 
have   just    been    drinking.'      At    last    she    reached    Lagny, 

*  Portal,  '  Observations  sur  la  Nature  et  le  Traitement  des  Maladies 
du  Foie,'  p.  170.     Paris,  1813. 

t  Durand-Fardel,  '  Maladies  des  Vieillards.'     Paris,  1854. 


SUDDEN  DEATH. 


where  she  was  met  b}^  her  friends  ;  but  as  her  pain  kept 
getting  worse,  they  took  her  to  a  hotel  near  the  station. 
A  physician  who  was  called  in  haste  reassured  th^m,  and 
told  them  that  the  patient  was  suffering  from  biliary  colic. 
The  pains  increased,  however,  and  the  young  woman  died 
in  the  night.  The  event  caused  considerable  sensation  at 
the  hotel;  inquiries  were  made,  and  some  astonishment 
was  expressed  when  the  circumstances  were  ascertained 
under  which  she  had  left  Paris.  The  superintendent  of 
police  intervened,  and  the  body  was  sent  to  the  Morgue, 
where  a  post-mortem  examination  was  made. 

Post-mortem.  —  The  bile-duct  contained  a  good -sized 
calculus,  and  there  were  many  more  in  the  gall-bladder. 
The  most  curious  feature  observed  at  the  autopsy  was  the 
fact  that  the  lumen  of  the  duodenum  was  completely 
obstructed.  There  was  collateral  oedema  of  the  coats  of 
the  intestine,  the  mucous  membrane  being  raised  to  such 
a  degree  as  to  make  an  absolutely  resistant  tube. 

[In  a  case  observed  by  myself,  fatal  syncope  happened 
during  an  attack  of  biliary  colic.  Post-mortem. — A  gall-stone 
of  considerable  size  was  found  lying  in  the  duodenum,  and 
evidently  had  recently  passed.  The  liver  presented  numerous 
small  nodules  of  cancer. — Translator.] 

Allow  me,  in  connexion  with  this  subject,  to  make  a 
short  incursion  into  the  domain  of  clinical  medicine.  When 
examining  patients  suffering  from  biliary  colic,  there  is 
often  found  dulness  on  percussion  over  the  region  of  the 
liver,  and  the  question  is  raised  whether  this  is  caused  by 
a  distended  gall-bladder  or  Spigelian  lobe.  I  am  inclined 
to  believe,  judging  from  the  result  of  this  autopsy,  that  this 
dulness  is  sometimes  due  to  distension  of  the  duodenum. 
This  case  is  almost  unique,  and  it  is  very  interesting.  How 
could  sudden  death  take  place  without  perforation,  or  any 
other  grave  anatomical  lesions  ?  Death  is  certainly  due  to 
stoppage  of  the  heart,  determined  by  a  reflex  inhibition 
due  to  excitation  of  the  pneumogastric  filaments  distributed 
over  the  liver. 

Ruptures  of  the  gall-bladder  and  biliary  ducts  are  possible. 
I   have   never    met   with    a    case   where    the    passage   of   a 


LESIONS  OF  THE  DIGESTIVE  SYSTEM.  223 

calculus  has  caused  a  rupture  or  laceration,  and  thus 
brought  about  an  escape  of  bile  into  the  peritoneal  cavity. 
I  believe  that  when  these  lesions  occur  they  are  due  to 
some  other  cause ;  thus,  ulceration  of  the  gall-bladder  may 
take  place  in  typhoid  fever,  for  example.  In  other  instances, 
the  presence  of  a  gall-stone  may  set  up  inflammation  of 
the  gall-bladder ;  but  then  adhesions  form  betw^een  the 
peritoneum,  the  gall-bladder,  and  the  intestine,  and  ulcera- 
tion, if  it  happens  at  all,  does  not  give  rise  to  a  perforation 
into  the  peritoneal  cavity,  but  into  the  intestine,  and  there 
is  not  the  same  danger. 

Hydatid  cysts  of  the  liver  may  burst  into  the  peritoneal 
cavity.  When  the  cysts  are  large,  their  existence  is 
usually  w^ell  known  to  the  physician  and  the  patient's 
friends,  if  not  to  the  patient  himself.  But  if  no  one 
knows  of  their  existence,  what  will  happen  ?  The  patient 
may  die  suddenly  in  profound  collapse.  He  will  not 
present  the  symptoms  of  acute  peritonitis,  although  there 
is  inflammation  of  the  peritoneum.  He  will  die  with 
choleraic  symptoms,  and  if  death  supervenes  under  condi- 
tions that  are  at  all  peculiar,  the  law  will  intervene,  and 
an  autopsy  will  be  ordered. 

Tardieu  records  the  following  case :  A  husband  surprised 
his  wife  in  flagrante  delicto  of  committing  adultery.  A  violent 
scene  took  place  between  the  three  actors  in  the  drama,  and 
the  husband  ran  to  find  the  superintendent  of  police.  On 
his  return  he  found  his  wife  unconscious  and  collapsed,  and 
she  died  in  the  course  of  three  hours  with  choleraic  symptoms : 
diarrhoea,  vomiting,  suppression  of  urine,  etc.  How  could 
any  one  believe,  in  spite  of  the  denial  of  the  husband  and  lover, 
that  no  violence  had  been  inflicted?  A  medico-legal  autopsy 
was  ordered,  and  death  was  found  to  be  due  to  the  rupture  of 
a  hydatid  cyst  into  the  peritoneal  cavity.  Was  the  rupture 
due  to  an  act  of  violence  ?  The  body  showed  no  trace  of  it, 
and  probably  there  had  been  none. 

VI.  LESIONS  OF  THE  SPLEEN. 

Lesions  of  the  spleen  do  not  often  give  rise  to  medico- 
legal intervention  in  our  own  country,  but  in  those  lands 
where  malarial  fevers  prevail  it  is   quite  otherwise.      The 


224  SUDDEN  DEATH. 


spleen  may  burst  as  a  result  of  very  great  violence,  such  as 
a  crush  of  the  body  or  a  fall  from  a  height. 

A  man  took  his  mother-in-law  for  a  drive  in  a  tilbury. 
The  tilbury  was  overturned  in  such  an  unlucky  manner  that 
the  man  fell  on  the  top  of  his  mother-in-law,  and  the  latter 
died  almost  immediately.  The  man  escaped  unhurt.  There 
was  a  medico-legal  investigation,  because  of  the  circum- 
stances in  which  the  accident  took  place.  At  the  autopsy, 
the  spleen  was  found  to  be  ruptured. 

The  spleen  may  also  be  ruptured  during  the  straining  of 
childbirth,  especially  when  labour  is  difficult. 

In  warm  climates — in  countries  where  intermittent  fever 
prevails — the  spleen  of  those  individuals  who  have  undergone 
frequent  attacks  of  malarial  fever  becomes  hard,  and  it  also 
becomes  extraordinarily  fragile.  Dr.  Pellereau,  who  practised 
in  the  Isle  of  Bourbon,  has  published  the  result  of  seventeen 
medico-legal  autopsies,  in  which  he  shows  that  the  spleen 
may  be  ruptured  by  very  slight  violence  ;  he  relates,  for 
example,  the  history  of  an  individual  who  was  running 
across  some  fields,  and  was  struck  light'y  in  the  splenic 
region  by  the  branch  of  a  cactus  that  he  brushed  against  in 
passing.  This  injury,  if  it  deserves  the  name,  caused  a 
rupture  of  the  spleen  and  fatal  haemorrhage  into  the  peri- 
toneal cavity. 

I  myself  have  been  consulted  about  a  similar  case  : 

A  gentleman,  occupying  a  very  good  social  position  in  the 
department  of  Charente-Inferieure,  was  accused  of  killing 
one  of  his  friends  in  the  course  of  a  dispute.  There  had 
actually  been  a  little  scuffling,  in  the  course  of  which  the 
friend  had  been  pushed  against  a  writing-table,  but  with  so 
little  force  that  he  paid  no  attention  to  it,  and  made  no 
complaint  about  it  at  the  moment.  He  returned  home, 
and  when  he  arrived  there  he  became  ill.  He  rapidly  became 
blanched,  and  died.  A  medico-legal  autopsy  was  ordered. 
The  medical  jurist  who  made  it  found  the  spleen  ruptured, 
and  concluded  that  the  dead  man's  friend  was  to  blame. 
He  stated,  however,  that  the  spleen  was  hard,  but  not  much 
enlarged. 

When  the  physician  drew  up  his  report,  he  had,  however. 


LESIONS  OF  THE  DIGESTIVE  ORGANS.  225 

only  consulted  the  works  of  European  authors,  who  do  not, 
or,  rather,  who  did  not,  mention  the  special  fragihty  of  the 
spleen  in  persons  who  have  inhabited  warm  climates,  and 
have  had  attacks  of  intermittent  fever  there.  I  remembered 
this  fact  when  I  was  called  upon  to  make  a  further  report, 
and  I  learnt  that  the  deceased  had  formerly  been  a  naval 
officer,  who  had  been  invalided  in  consequence  of  frequent 
attacks  of  malarial  fever,  which  made  his  continuance  in 
the  service  quite  impossible.     The  proceedings  were  stayed. 

VII.  LESIONS  OF  THE  PANCREAS. 

We  shall  pass  rapidly.  Gentlemen,  over  lesions  of  the 
pancreas.  Even  if  we  understood  something  of  its  functions, 
we  do  not  know  much  about  its  pathology.  In  the  autopsies 
that  I  have  made,  I  have  sometimes  found  haemorrhages  in 
the  pancreas.  As  death  was  due  in  these  cases  either  to 
pulmonary  congestion  or,  as  in  the  case  of  the  young  woman 
that  I  related  to  you  a  little  while  ago,  to  biliary  colic,  I  am 
forced  to  believe  that  pancreatic  haemorrhage  is  a  concomi- 
tant, and  not  an  essential  lesion. 

VIII.   LESIONS  OF  THE  SUPRARENAL  CAPSULES. 

I  shall  not  speak  at  any  greater  length  on  this  subject. 
M.  Letulle  has  related  two  cases  of  sudden  death  in  cachectic 
individuals,  and  in  the  autopsy  on  each  he  found  advanced 
tuberculization  of  the  suprarenal  capsules.  [Addison's  dis- 
ease ? — Translator.] 

I  shall  not  add  any  more  to  what  I  have  already  said  in 
the  course  of  these  lectures  about  lesions  of  the  peritoneum. 
Remember  only  that,  from  the  medico-legal  point  of  view, 
there  are  fatal — even  rapidly  fatal — forms  of  peritonitis, 
which  do  not  present  the  usual  symptoms  of  peritonitis. 
These  cases  of  peritonitis,  on  the  contrary,  give  rise  to 
phenomena  which  we  can  only  call  choleraic,  such  as  sup- 
pression of  urine,  aphonia,  vomiting,  diarrhoea,  and  collapse. 

The  same  may  happen  in  tuberculosis  and  cancer  of  the 
peritoneum. 


15 


LECTURE  VII. 

SUDDEN   DEATH    CAUSED  BY  LESIONS   OF   THE  FEMALE 
GENITAL  ORGANS. 

Gentlemen, — It  might  appear  reasonable  to  divide  this 
chapter  into  two  sections,  one  relating  to  lesions  of  the 
genital  organs  in  pregnant  women,  the  other  relating  to 
lesions  of  the  same  organs  in  women  who  are  not  pregnant. 
This  plan  would  lead  to  numberless  repetitions. 

A.  VAGINAL  EXAMINATION. 

Allow  me  to  draw  your  earnest  attention  to  a  very  impor- 
tant point.  You  may  be  exposed  in  certain  cases  to  sus- 
picions which  may  cast  discredit  upon  you  and  compromise 
your  reputation. 

In  a  woman,  whether  pregnant  or  not,  who  has  lesions  of 
the  uterus  or  its  appendages — fibroid  tumours,  for  example 
—simple  vaginal  examination,  such  as  a  physician  makes 
daily  in  his  consulting-room,  may  cause  sudden  death. 

I  remember  that,  when  I  was  house-physician,  I  was  one 
evening  with  my  colleague,  Chas.  Martin,  in  Gosselin's 
wards,  by  the  side  of  a  bed  in  which  was  lying  a  woman, 
on  whom  he  had  to  make  a  vaginal  examination.  He  made 
the  examination,  and  then  went  to  wash  his  hands.  The 
woman  died  suddenly,  without  M.  Martin,  who  was  washing 
his  hands  at  the  end  of  the  ward,  or  even  myself,  who  was 
by  the  bedside,  being  able  to  render  any  aid,  however  quick 
we  might  have  been.  Post-mortem  we  only  found  a  fibroid 
tumour.  All  the  organs  were  healthy.  When  I  exhibited 
the    specimens    at    a   meeting   of  the   Anatomical   Society, 


LESIONS  OF  THE  FEMALE  GENITAL  ORGANS.       227 

Dr.  Barth  related  to  the  society  three  or  four  similar  cases 
that  had  occurred  in  his  own  practice. 

Some  years  later  Lorain  published  the  following  case : 

A  girl,  16  years  of  age,  who  had  contracted  gonorrhoea, 
although  she  had  the  signs  of  virginity,  was  admitted  under 
his  care.  Lorain  himself  administered  an  injection  through 
the  orifice  of  the  hymen,  by  means  of  a  syringe  with  wings. 
The  operation  was  very  simple,  and  the  introduction  of  the 
tube  of  the  syringe  could  not  cause  any  injury.  At  the  fourth 
injection  the  girl  died  suddenly. 

Twice  within  my  own  knowledge  it  has  happened  that 
women  have  died  in  the  consulting-room  of  a  physician 
who  had  simply  made  a  vaginal  examination.  You  see  what 
would  be  the  consequences  of  an  accident  of  this  sort  :  the 
physician  is  obliged  to  give  notice  to  the  superintendent 
of  police  that  there  is  a  corpse  in  his  house  ;  a  romance, 
a  legend,  is  quickly  invented ;  if  the  deceased  woman  was 
pregnant,  and  if  she  had  said  to  her  neighbours  that  she 
regretted  her  condition,  the  physician  will  be  accused  of 
having  attempted  to  procure  abortion.  Tardieu*  has  very 
justly  compared  these  sudden  deaths  with  those  which  take 
place  in  abortion. 

In  country  places  the  physician  will  be  in  a  very  awkward 
situation  in  the  presence  of  such  rumours  and  of  the  public 
hostility,  which  will  not  always  be  allayed  even  when  the 
result  of  the  autopsy  is  made  known,  and  he  will  often  have 
great  difficulty  in  recovering  his  reputation  after  such  attacks 
have  been  made  upon  it. 

Simple  vaginal  examination  may  also  have  another  conse- 
quence. 

M.  Tarnier  stated  in  the  Court  of  Assizes  that  women 
have  twice  come  to  him  in  order  to  submit  to  such  an 
examination,  and  have  aborted  the  same  evening,  and  yet 
neither  of  them  wished  for  abortion  to  take  place. 

This  is  an  extremely  interesting  chapter  from  the  point  of 
view  of  medical  responsibility.  If  we  ask  ourselves  to  what 
cause  these  sudden  deaths  are  to  be  attributed,  what  I  have 

*  Tardieu,  'Etude  medico-legale  sur  I'Avortement,'  4''  edition.  Paris, 
1881. 


228  SUDDEN  DEATH. 


already  said   to  you  concerning  inhibition  and  the  following 
remark  will  enable  you  to  explain  the  process. 

Superficial  lesions  sometimes  suffice  to  bring  on  palpita- 
tion or  intermission  of  the  pulse  even  in  robust,  though  very 
nervous,  women,  without  any  lesion  of  the  heart ;  cauter- 
ization of  a  small  ulcer  on  the  cervix  of  the  uterus  will  make 
this  palpitation  and  intermission  cease.  Is  not  that  a  proof 
of  the  intimate  relation  that  exists  between  the  innervation 
of  the  genital  organs  and  that  of  the  heart  ? 

B.  EXTRA-UTERINE  GESTATION. 

Sudden  death  may  supervene  in  the  course  of  extra- 
uterine gestation.  This  gestation  may  be  interstitial  or 
tubal.  It  seldom  reaches  the  normal  term.  Sometimes 
the  foetus  does  not  die  until  pregnancy  is  far  advanced  ;  it 
may  remain  for  a  time  in  the  true  pelvis,  and  be  then 
discharged  in  fragments. 

Whatever  may  be  the  course  of  events  in  extra-uterine 
gestation,  suppose  a  woman  is  the  subject  of  it,  in  what 
circumstances  will  the  intervention  of  the  law  be  called  for  ? 

Allow  me,  Gentlemen,  to  recall  to  you  a  case  that  I 
referred  to  when  I  was  speaking  to  you  of  the  tension  of 
gases  produced  by  putrefaction  {vide  p.  loi). 

A  celebrated  actress  came  to  Paris  with  her  maid  and  two 
American  travelling  companions,  who  did  not  knov/  a  word 
of  French.  They  went  for  a  walk  in  the  Bois  de  Boulogne. 
During  the  walk  the  actress  felt  unwell  ;  she  was  taken  to 
the  Pre-Catelan,  where  she  drank  a  glass  of  milk  ;  as  she 
became  worse,  she  was  obliged  to  stop  at  the  Armenonville 
Pavilion,  where  she  died.  I  told  you  that  an  Englishman 
of  high  social  position  had  time  to  reach  Paris  before  the 
autopsy;  he  found  me  at  the  Morgue,  and  the  first  words 
that  he  said  to  me  were,  *  It  is  not  possible  for  this  woman 
to  be  pregnant ;  I  have  very  good  reason  to  be  certain.'  I 
assented.  The  actress  had  a  three-months  tubal  pregnancy, 
and  the  foetal  cyst  had  ruptured  into  the  peritoneal  cavity  ; 
the  young  woman  had  therefore  died  of  intra-peritoneal 
haemorrhage.     I  told  the  English  lord  that  she  had  died  of 


LESIONS  OF  THE  FEMALE  GENITAL  ORGANS.      229 

rupture  of  the  veins  of  the  ovarian  plexus  into  the  peritoneal 
cavity  ;  the  precise  cause  of  death  I  only  stated  in  my  official 
report. 

The  public,  which  was  much  excited  about  the  death  of 
this  distinguished  actress,  learnt  from  the  journals  of  the 
day,  which  pride  themselves  on  being  well  informed,  that  I 
attributed  the  mishap  to  the  fact  that  the  young  woman  had 
drunk  a  glass  of  cold  milk  at  the  Pre-Catelan. 

I  will  quote  a  second  case  to  you  : 

A  young  physician,  who  took  his  degree  in  1884,  set  up 
in  practice  in  Paris,  and  took  into  his  service  a  maid, 
24  years  of  age.  One  evening  he  went  out  after  dinner, 
and  when  he  returned  from  his  walk  he  found  a  mob  in 
front  of  his  door,  and  the  hall -porter  was  in  a  great  rage. 
The  maid  was  dying  of  loss  of  blood,  and  expired  soon 
after.  The  young  physician  was  immediately  accused  of 
having  treated  his  maid  as  if  she  were  his  mistress,  and  of 
having  attempted  to  procure  abortion.  The  body  was 
removed  to  the  Morgue,  and  the  autopsy  revealed  the  exist- 
ence of  a  tubal  pregnancy  of  three  months'  duration,  with 
rupture  of  the  foetal  cyst  into  the  peritoneal  cavity. 

The  unfortunate  doctor,  in  spite  of  the  conclusions  of  my 
report,  was  obliged  to  leave  that  quarter  and  set  up  in 
another  part  of  Paris,  a  long  way  from  his  former  residence. 

Gentlemen,  you  are  young ;  allow  me  to  give  you  a  piece 
of  advice :  when  a  physician  is  young  and  unmarried,  he 
ought  only  to  take  into  his  service  females  who  are  plain 
and  who  have  passed  the  canonical  age. 

C.   RETRO-UTERINE  HEMATOCELE. 

Besides  these  tubal  or  abnormal  pregnancies,  apart  even 
from  pregnancy  at  all,  death  may  take  place  from  haemor- 
rhage into  the  peritoneal  cavity.  Bernutz  has  applied  the 
term  '  hsematocele  '  to  such  conditions. 

Here  is  an  example  which  is  all  the  more  interesting  be- 
cause the  patient  recovered,  and  I  was  able  to  follow  up  the 
case  for  a  long  time  afterwards :  A  lady  was  taking  up  her 
quarters  in  a  new  lodging,  and  was   standing  on  a  pair  of 


230  SUDDEN  DEATH. 


steps  ;  though  she  was  not  making  any  violent  effort,  she 
was  taken  ill  and  I  was  sent  for  ;  I  found  her  completely 
bloodless,  though  not  losing  blood  by  any  external  orifice. 
My  assistant  and  1  took  it  in  turn  to  stay  near  the  patient, 
spending  four  whole  days  thus,  and  giving  her  an  injection 
of  caffeine  or  of  ether  every  ten  minutes.  The  woman  was 
unconscious,  scarcely  alive.  Thanks  to  the  teaching  of  my 
master,  Bernutz,  I  recognized  the  existence  of  a  pelvic 
hasmatocele,  although  the  most  careful  exploration  did  not 
yield  any  evidence  of  it.  It  was  only  on  the  third  day,  when 
it  had  become  encysted,  owing  to  the  formation  of  false 
membranes  due  to  peritoneal  irritation,  that  it  became 
possible  to  confirm  the  truth  of  the  diagnosis. 

Cases  of  this  kind  do  not  always  pursue  such  a  fortunate 
course.  They  may  sometimes  give  rise  to  sudden  death. 
Gallard  asserted  that  haematoceles  were  always  due  to 
rupture  of  a  foetal  cyst  in  an  extra-uterine  gestation,  and 
that  careful  search  would  always  detect  a  corpus  lutetim, 
which  would  reveal  the  nature  of  the  disease. 

Virchow  attributes  the  formation  of  hsematoceles  to  the 
rupture  of  extremely  fragile  and  highly  vascular  false  mem- 
branes, similar  to  those  of  pachymeningitis,  consecutive  to 
an  attack  of  inflammation  of  the  peritoneal  pouches.  The 
origin  of  such  conditions  really  matters  very  little,  so  long 
as  we  recognize  their  existence. 

D.  RUPTURE  OF  THE  UTERUS. 

In  natural  pregnancy  the  uterus  may  sometimes  rupture  in 
the  second  month,  under  the  influence  of  a  strain  or  slight 
violence.  I  have  never  met  with  an  accident  of  the  kind, 
but  Moynier  has  reported  a  case. 

E.  VULVO-VAGINAL  VARICES. 

In  certain  women,  most  often  during  the  second  or  third 
pregnancy,  vulvo-vaginal  varices,  sometimes  of  considerable 
size,  may  be  met  with.  They  are  even  found  in  primiparae. 
These  varicose  clusters  may  be  almost  imperceptible ;  in 
some  cases  they  may  attain  the  size  of  the  foetal  head.    These 


LESIONS  OF  THE  FEMALE  GENITAL  ORGANS.       231 


varices  may  burst  as  a  result  of  an  effort  during  delivery,  or 
even  apart  from  delivery.  The  blood  escapes  externally, 
and  the  woman  may  die  of  haemorrhage. 

I  once  had  to  perform  a  medico-legal  autopsy  at  the 
Morgue,  together  with  MM.  Tarnier  and  Champetier  (of 
Ribes),  on  the  body  of  a  woman  who  was  suspected  of 
having  procured  abortion  ;  we  did  not,  however,  find  any 
evidence  of  abortion,  but  a  considerable  bundle  of  vaginal 
varices  ;  nevertheless,  it  was  impossible  to  discover  the 
opening  from  which  the  blood  had  flowed. 

This  is  not  an  isolated  instance.  When  a  woman  dies 
under  these  conditions,  the  laceration  of  the  varicose  vein 
is  no  longer  discoverable,  because  the  varices  are  no  longer 
distended  by  liquid ;  it  would  be  necessary  to  inject  the 
varicose  cluster  in  a  way  that  might  be  possible  in  the  post- 
mortem theatre,  but  this  would  not  be  an  easy  matter  in  a 
medico-legal  autopsy,  where,  when  there  is  a  suspicion  of 
abortion,  we  examine  the  uterus,  its  appendages,  and  the 
placenta  (if  it  exists),  before  thinking  of  varicose  veins  in 
the  vulva  and  vagina.  At  any  rate,  I  do  not  know  of  a 
single  medico-legal  autopsy  in  which  the  orifice  by  which 
blood  has  escaped  has  been  found  in  a  cluster  of  varicose 
veins. 

When  rupture  of  these  varicose  veins  takes  place  during 
delivery,  at  the  moment  when  the  fcetal  head  passes,  it  is 
impossible  to  be  in  any  doubt  as  to  the  nature  and  cause  of 
the  haemorrhage.  But  it  is  otherwise  when  the  rupture 
takes  place  before  labour  begins. 

There  may  be  sudden  and  suspicious  deaths  during 
delivery.  Moynier  has  reported  cases  of  rupture  of  the 
utero-ovarian  plexus,  but  this  is  very  rare. 

F.  SYNCOPE. 

Here  is  another  accident,  which  is  more  frequent.  When 
a  woman  is  confined,  she  may  have  an  attack  of  syncope. 
The  fact  is  certain.  When  the  birth  is  secret,  and  espe- 
cially in  cases  of  infanticide,  the  accused  woman  always 
says  that  she  became  unconscious  and  did  not  know  what 


232  SUDDEN  DEATH. 


was  happening,  and  that  when    she  recovered  her  senses 
she  found  the  child  dead  between  her  thighs. 

At  the  assizes,  the  judge  will  ask  you  if  such  attacks  of 
syncope  are  common  ;  they  are  possible,  but  they  are  not 
frequent  under  normal  conditions.  I  was  much  surprised 
to  read  in  a  lengthy  memoir  by  Freyer,  a  distinguished 
obstetrician  of  Berlin,  that  out  of  165  confinements  he  had 
met  with  34  cases  of  syncope.  Dr.  Freyer  expresses  no 
astonishment  at  this  proportion  ;  he  appears  to  consider  it 
natural,  and  he  does  not  relate  the  circumstances  in  which 
these  syncopal  attacks  took  place.  There  is  an  enormous 
difference,  in  this  matter,  between  our  experience  in  France 
and  that  which  Freyer  describes. 

Moreover,  statistics  are  not  of  much  importance ;  the 
interest  to  us  lies  in  the  conditions  under  which  syncope 
may  present  itself. 

Is  syncope  more  common  among  women  who  are  confined 
in  secret  ?  Perhaps.  These  women,  of  course,  do  not  wish 
anybody  to  know  of  their  delivery  ;  they  have  determination 
enough  to  suppress  all  cries  and  groans ;  it  may  be  that  the 
very  excess  of  pain  may  bring  on  syncope  in  them. 

This  is  probably  the  most  frequent  mode  by  which  syncope 
is  produced  in  those  women  who  are  confined  secretly;  yet 
this  syncope  may  also  be  determined  by  an  attack  of 
haemorrhage  or  some  other  obstetrical  accident,  since  there 
is  no  competent  person  present  to  prevent  or  check  it. 

G.  CHLOROFORM. 

You  know  that  of  late  years  it  has  been  customary  to 
administer  chloroform  during  labour.  Obstetrical  anaes- 
thesia is  not  so  deep  as  surgical  anaesthesia,  I  admit.  Yet 
there  have  been  deaths  to  deplore.  Ought  these  deaths  to 
be  attributed  to  chloroform  ?  Is  it  not  possible  for  syncope 
to  come  on  in  women  who  are  under  the  influence  of  chloro- 
form just  as  in  those  who  are  not  ?  I  point  out  to  you  the 
possibility  of  these  accidents,  for  they  may  give  rise  to  very 
embarrassing  problems  ;  the  responsibility  of  the  physician 
or  midwife  may  be  questioned,  and  you  may  be  called  upon 
to  decide  the  question. 


LESIONS  OF  THE  FEMALE  GENITAL  ORGANS.        233 

A  certain  number  of  sudden  deaths  after  confinement,  and 
sometimes  in  pregnancy  (for  the  pathogeny  is  the  same),  are 
attributable  to  venous  thrombosis  and  embohsm.  I  shall 
not  repeat  what  I  have  already  said  on  this  subject,  while 
studying  with  you  the  lesions  of  the  circulatory  system.  In 
pregnant  women,  thrombosis  of  the  veins  of  the  lower  ex- 
tremities and  of  the  vena  cava  may  take  place  before 
confinement ;  the  straining  of  the  woman  during  the  act  of 
parturition  may  dislodge  the  clot,  which  is  then. precipitated 
into  the  circulatory  stream. 

Finally,  sudden  deaths  have  been  observed  due  to  abscess 
of  the  ovary,  53  hours  after  delivery  ;  but  I  do  not  lay  much 
stress  upon  this. 


LECTURE    VIII. 

SUDDEN  DEATH  IN  FEVERS. 

Gentlemen, — There  are  certain  fevers  in  which  death  may 
occur  in  a  sudden  and  somewhat  unexpected  manner,  and 
therefore  give  rise  to  medico-legal  intervention. 

You  know  what  intermittent  fever  is,  Gentlemen,  with  its 
pernicious  forms — algid,  comatose,  and  choleraic. 

You  are  aware  that  an  attack  may  be  pernicious  from  the 
very  beginning,  without  the  patient  having  had  any  attacks 
of  fever  previously  ;  that  algidity  may  show  itself  along  with 
the  initial  rigor — i.e.,  in  the  first  stage  ;  that  the  comatose 
form  usually  appears  at  the  end  of  the  second  stage;  and  that 
the  choleraic  phenomena  present  themselves  in  the  sweating 
stage. 

These  different  forms  of  attack  may,  however,  be  mixed 
up,  and  become  '  subintrant,'  and  there  are  all  sorts  of  ways 
in  which  it  is  possible  for  death  to  take  place  under  suspicious 
circumstances  at  any  period  of  the  disease.  Death  may 
occur  in  the  first  attack  ;  it  may  occur  in  the  first  stage  with 
as  much  likelihood  as  in  the  second  or  third. 

In  those  countries  where  pernicious  fever  is  rare,  attacks 
of  this  class  are  nearly  always  misinterpreted.  From  the 
medico-legal  point  of  view,  the  medical  jurist  intervenes  all 
the  more  frequently  in  fatal  cases  of  pernicious  fever,  in  pro- 
portion to  their  rarity,  because  public  opinion  does  not 
know  to  what  cause  to  assign  them  ;  i.e.,  in  countries  where 
cases  of  intermittent  fever  are  fewest,  medico-legal  interven- 
tion is  at  its  inaximiim,  and  in  countries  where  such  fever  is 
prevalent,  medico-legal  intervention  is  at  its  ininimum. 


SUDDEN  DEATH  IN  FEVERS.  235 

In  the  hasmorrhagic  forms  of  certain  exanthemata,  such  as 
small-pox  and  scarlet  fever,  death  may  happen  suddenly, 
especially  in  pregnant  women.  When  the  hemorrhagic  form 
of  the  disease  has  not  been  recognized,  the  medical  jurist 
may  be  directed  to  make  an  autopsy. 

I  shall  not  enumerate  here  the  causes  which  may  lead  to 
sudden  death  in  fevers  or  infective  diseases,  either  during 
their  course  or  during  convalescence.  We  have  drawn 
attention  to  them  already  when  studying  myocarditis,  endo- 
carditis, thrombosis,  embolism,  syncope,  etc. 

You  will  find  them  set  forth  at  length  in  systematic 
treatises. 


LECTURE    IX. 

SUDDEN  DEATH  DUE  TO  HEMOPHILIA. 

Gentlemen, — I  come  now  to  sudden  and  suspicious  death 
due  to  humoral  changes  ;  I  use  this  term  in  a  somewhat  elastic 
sense,  so  as  to  include,  haemophilia,  diabetes,  uraemia,  and 
alcoholism. 

Hmnophilia  is  a  rare  affection,  and  on  that  account  does 
not  often  give  occasion  for  medico-legal  intervention.  But 
when  this  is  required,  the  medical  jurist  will  find  himself 
beset  with  very  great  difficulties. 

Haemophilia  may  occur  in  isolated  cases,  or  it  may  run 
through  families. 

When  a  bloodvessel  is  opened  in  one  of  these  subjects,  it 
is  almost  impossible  to  arrest  the  haemorrhage.  When  a 
man  who  is  the  subject  of  haemophilia  dies  of  haemorrhage, 
would  it  have  been  possible  to  stop  that  haemorrhage  ? 

You  see  that  the  question  of  responsibility  crops  up  at 
once  ;  there  is  the  responsibility  of  the  drugrgist  to  whom 
the  man,  who  has  just  become  unconscious,  is  carried,  and 
the  responsibility  of  the  physician  who  has  been  called  in 
to  render  first  aid.  The  examples  that  I  am  going  to  cite 
to  you,  Gentlemen,  will  enable  you,  I  think,  to  form  an 
opinion. 

Thirty  years  ago,  a  youth,  14  or  15  years  of  age,  neither  of 
whose  parents  was  the  subject  of  haemophilia,  fell  down  in 
the  Rue  de  I'Odeon  and  cut  his  lip,  causing  haemorrhage. 
The  lad  was  taken  to  his  parents'  house,  which  was  in  the 
same  street,  and  they  sent  for  me.  In  spite  of  my  long- 
continued  efforts,  I  found  it  impossible  to  stop  the  haemor- 


SUDDEN  DEATH  DUE  TO  HEMOPHILIA.  237 

rhage  ;  I  sent  for  my  master,  Dr.  P.  Lorain,  who  was  no 
more  successful.  We  summoned  Nelaton  and  Gosselin  to  a 
consultation,  but  the  hemorrhage  could  not  be  arrested,  and 
the  lad  died  m  the  night. 

Eighteen  months  afterwards,  Gentlemen,  this  lad's  sister 
was  married.  On  her  bridal  night  hsemorrhage  ensued  in 
consequence  of  the  rupture  of  the  hymen ;  she  died  twelve 
hours  after,  without  any  of  the  physicians  or  surgeons  who 
were  collected  round  her  bed  being  able  to  check  the 
haemorrhage.  How  does  forensic  medicine  come  to  inter- 
vene in  these  cases  of  sudden  death  in  haemophilia  ?  I  have 
had  personalty  to  deal  with  two  such  cases,  and  in  almost 
identical  circumstances. 

A  young  man  went  to  his  barber,  who  combined  the  pro- 
fession of  dentist  with  that  of  hairdresser.  After  having  cut 
the  hair  or  the  beard  of  his  customer,  the  barber,  noticing 
that  he  had  a  decayed  tooth,  persuaded  him  to  have  it 
extracted.  He  extracted  the  tooth,  and  haemorrhage  took 
place.  Remember  that  at  that  time  the  practice  of  dentistry 
was  free,  and  that  the  law  which  regulates  it  at  the  present 
time  did  not  then  exist.  The  barber,  not  knowing  how  to 
stop  the  haemorrhage,  took  his  customer  to  a  chemist,  who 
applied  plugs  of  perchloride  of  iron,  but  in  vain.  The  patient 
was  then  carried  to  St.  Antoine  Hospital,  where  he  died. 
Was  the  barber-dentist  responsible  for  the  young  man's 
death  ?  The  widow  brought  an  action  against  him  for 
damages,  and  at  that  point  I  was  commissioned  as  an  expert. 
Was  the  young  man  the  subject  of  haemophilia  ?  Perhaps 
he  was,  but  he  was  not  aware  of  it ;  no  more  was  the  barber. 
The  father,  mother,  and  brother  of  the  deceased  were  still 
living,  and  we  could  not  discover  any  trace  of  the  disease  in 
them. 

In  the  second  case,  on  the  contrary,  a  very  celebrated 
dentist,  who  possessed  many  qualifications  and  diplomas, 
was  involved.  A  young  v/oman  who  was  about  to  be  married 
was  taken  to  him.  He  examined  her  teeth  and  recommended 
the  extraction  of  a  stump  ;  the  stump  was  removed,  and 
haemorrhage  immediately  followed,  which  it  was  quite  im- 
possible to  stop,  and  the  young  woman  died.     The  dentist, 


238  SUDDEN  DEATH. 


it  seems,  had  lost  his  head  somewhat  when  this  accident 
took  place.     He  went  away  repeating  : 

'  Oh,  my  God  !  it  is  I  who  have  killed  her  !  it  is  I  who 
have  killed  her  !' 

The  family,  whose  suspicions  were  aroused  by  these  im- 
prudent words,  on  the  advice  of  a  physician  who  did  not 
think  of  its  being  a  case  of  haemophilia,  and  who  expressed 
the  opinion  that  '  powerful '  haemostatics  should  have  been 
used,  brought  an  action  against  the  dentist. 

I  had  to  be  very  reserved  in  my  conclusions,  for,  in  spite 
of  the  absence  of  any  hereditary  taint,  it  was  not  demon- 
strated that  the  girl  was  not  the  subject  of  haemophilia. 

The  great  danger  of  haemophilia  is  that  neither  the  subjects 
of  it  nor  those  in  habitual  intercourse  with  them  are  aware 
of  the  fact.  The  slightest  injury  may  induce  a  catastrophe 
in  them. 


LECTURE  X. 

SUDDEN  DEATH  IN  DIABETES. 

Gentlemen, — Diabetes  is  the  disease  of  all  others  which 
runs  the  longest  course  without  its  subject  being  aware  of  it, 
whatever  may  be  the  quantity  of  sugar  voided  in  twenty- four 
hours.  The  ordinary  diabetic  is  a  man  who  has  a  good 
stomach  and  digestion,  who  appears  to  be  in  good  health  up 
to  the  moment  at  which  he  enters  upon  what  may  be  called 
the  '  pathological  period,'  which  is  revealed  by  a  succession 
of  boils,  loss  of  teeth,  ocular  troubles,  etc.  The  common 
belief  is  that  the  diabetic  passes  much  urine,  but  sometimes 
this  is  not  the  case  at  all,  and  at  other  times  the  patient 
scarcely  notices  it.  He  drinks  more,  perhaps,  than  other 
people,  therefore  it  seems  only  natural  to  him  to  make  water 
more  freel}'  and  more  frequently ;  moreover,  if  the  quantity 
of  urine  passed  increases  little  by  little  every  day,  there  is 
not  sufficient  difference  between  one  day  and  another  to 
attract  his  attention.  Diabetes  may  develop  in  an  entirely 
latent  manner.  I  am  persuaded  that  a  few  years  hence 
clinical  observers  will  be  able  to  break  up  the  group,  which 
is  at  present  regarded  as  homogeneous.  For  my  own  part, 
I  have  never  met  with  two  cases  of  diabetes  that  are  abso- 
lutely alike.  In  one  class  of  cases,  the  patients  are  fat,  in 
another  class  thin  ;  there  is  diabetes  with  excess  of  urea, 
and  diabetes  without  such  ;  but  classification  according  to 
these  varieties  does  not  afford  a  solid  basis  for  forming  a 
prognosis.  The  only  form  of  diabetes  which  I  would 
actually  separate  from  the  main  group  is  that  which  results 
from  an  injury — a  railway  accident,  for  example — and  which 


I40  SUDDEN  DEATH 


has  been  specially  studied  by  M.  Richardiere  and  myself.* 
This  form  is  more  curable  than  the  rest,  and  in  none  of 
these  cases  did  we  meet  with  accidents  such  as  those  that  I 
am  going  to  point  out  to  you. 

Certain  individuals,  whom  no  one  suspected  of  being  the 
subjects  of  glycosuria  (this  is  important,  for  it  alone  explains 
the  intervention  of  the  medical  jurist),  may  be  carried  off 
very  rapidly  by  a  great  variety  of  accidents.  They  may  die 
of  pulmonary  complications,  such  as  the  '  fulminating  pneu- 
monia '  of  Bouchardat.  This  form  of  pneumonia  is  only 
detected  24  or  36  hours  before  death  takes  place»  It  may 
develop  with  extreme  rapidity,  something  like  the  pneumonia 
of  the  aged,  but  it  is  accompanied,  however,  by  symptoms 
of  reaction  which  make  it  evident  that  the  patient  is  ill  24 
or  36  hours  before  he  dies. 

They  may  die  from  some  complication  of  a  wound  or  surgical 
operation.  You  know  that  before  the  introduction  of  anti- 
septic dressings  surgeons  hesitated  before  operating  on  a 
diabetic.  Gosselin  did  not  care  even  to  open  a  boil  in  such 
subjects.  Since  the  claims  of  antisepsis  have  become  estab- 
lished, it  has  been  shown  that  rapid  death  in  such  cases  is 
only  due  to  an  intensive  culture  of  streptococci  and  staphylo- 
cocci ;  but  it  is  true,  nevertheless,  that  diabetes  renders  the 
healing  of  a  wound  much  more  difficult. 

A  wholesale  mercer  of  the  Rue  de  Rivoli  slightly  abraded 
the  skin  over  the  crest  of  the  tibia  in  falling  over  a  footstool. 
He  was  carefully  treated  by  his  usual  medical  attendant,  who 
called  in  Trelat  to  a  consultation,  as  the  wound  did  not  heal. 
The  medical  attendant  being  taken  ill,  I  was  asked  to  take 
his  place.  I  was  then  house-physician  to  Aran,  and  the 
urine  was  systematically  examined  in  all  the  patients  under 
his  care.  I  therefore  examined  my  patient's  urine,  and 
found  that  it  contained  sugar.  The  next  day  but  one,  the 
brother  (a  notary)  and  sister  of  my  patient  begged  me  to 
examine  their  urine  also.  I  found  that  they  were  passing 
from  goo  to  1,200  grains  of  sugar  per  diem.  All  these  three 
persons  lived  for  more  than  20  years  without  ever  experienc- 

■-'-  Brouardel  et  Richardiere,  '  Du  Diabete  traumatique  au  Point  de  Vue 
des  Expertises  m^dico-legales '  {Anji.  d'Hyg.,  1888,  tome  xx.,  p.  204). 


IN  DIABETES.  241 


ing  any  disorder  that  might  be  attributed  to  diabetes.  My 
patient  in  particular  died  only  two  years  ago :  he  survived 
32  years  after  the  occurrence  of  the  above-mentioned  trifling 
accident,  and  he  would  never  have  known  that  he  had 
diabetes  but  for  that  wound  being  so  slow  in  healing. 

And  notwithstanding  the  great  advantages  which  anti- 
septic treatment  bestows  on  our  patients,  it  should  always 
be  ascertained,  before  undertaking  an  operation,  whether  or 
not  they  suffer  from  diabetes.  Death  may  take  place  in  an 
unforeseen  manner  in  diabetes.  The  form  which  most  often 
gives  rise  to  suspicion,  medico-legally  speaking,  is  that  which 
is  called  '  diabetic  coma.' 

All  observers  agree  in  saying  that  coma  sets  in  after  a 
phase  characterized  by  loss  of  appetite,  dyspepsia,  constipa- 
tion, vomiting,  pinched  face,  and  feeble  pulse,  indicating 
gastro  -  intestinal  disturbance.  These  symptoms  might 
suggest  peritonitis,  but  for  the  absence  of  pain  and  fever. 
There  is  also  a  peculiar  form  of  dyspnoea,  marked  by  ample, 
regular  and  slow  respiratory  movements.  This  dyspeptic 
period  lasts  from  36  to  48  hours  ;  then  the  patient  becomes 
comatose ;  the  temperature  in  the  axilla  falls  to  95°,  and 
there  is  loss  of  consciousness.  The  comatose  phase  lasts 
from  24  to  36  hours.  You  see  that  the  entire  process  lasts 
4  or  5  days  altogether. 

The  above  is  a  picture  of  diabetic  coma  as  it  was  first 
described.  Then  exceptions  were  discovered ;  cases  of 
diabetic  coma  were  met  with  which  were  comatose  from  the 
first,  the  abdominal  stage  being  quite  absent.  These  cases 
are  often  difficult  to  interpret,  and  they  may  easily  give  rise 
to  suspicion.  This  does  not  apply  to  those  persons  who 
know  that  they  are  diabetic,  and  whose  history  is  well  known 
in  towns  like  Vichy  or  Carlsbad,  where  they  spend  season 
after  season.  These  patients  pursue  a  course  of  treatment ; 
but  as  they  are,  or  think  they  are,  in  good  health,  they  make 
excursions,  go  to  the  Casino,  do  not  husband  their  strength, 
or  sometimes  they  overdo  their  treatment  because  they  have 
not  consulted  their  physician,  or  have  ceased  to  see  him. 
They  suddenly  fall  into  a  state  of  coma.     Such   cases  as 

16 


242  SUDDEN  DEATH 


these  have  been  well  studied  by  Cyr,*  a  physician  at  Vichy, 
who  died  a  few  years  ago. 

Cyr  has  described  another  variety,  of  which  I  myself  have 
seen  three  examples.  A  diabetic,  as  a  result  of  over-work, 
of  preoccupation,  or  of  cerebral  excitement,  becomes 
mentally  disturbed.  His  character  is  changed  :  he  becomes 
morose  and  difficult  to  live  with,  and  at  length  talks  in 
an  incoherent  manner,  which  I  can  only  compare  to  the 
babbling  of  individuals  in  the  first  stage  of  ansesthesia  from 
chloroform  ;  then  headache  and  giddiness  supervene,  and 
the  individual  suddenly  becomes  comatose.  Cyr  has  never 
observed  convulsions. 

If  any  member  of  the  patient's  family  or  any  of  his 
acquaintances  know  that  he  is  diabetic,  there  will  be  no 
medico-legal  difficulty.  But  if  no  one  was  aware  of  it, 
suspicions  of  poisoning  may  arise,  whether  or  not  there  may 
have  been  dyspeptic  troubles  before  the  comatose  period  is 
established. 

A  medico-legal  autopsy  will  be  ordered,  but  it  will  be 
without  result ;  the  medical  jurist  will  not  find  any  lesions 
on  which  conclusions  can  be  based.  His  only  chance  is  to 
find  urine  in  the  bladder,  and  sugar  in  that  urine  ;  unfortu- 
nately, the  bladder  is  most  often  empty.  In  case  of  poison- 
ing, as  a  general  rule,  the  autopsy  is  not  performed 
immediately  after  death ;  in  most  cases  exhumation  has  to 
be  performed.  The  difficulties  of  research  will  then  be  all 
the  greater,  and  even  if  liquid  is  found  in  the  bladder,  its 
composition  will  have  undergone  alteration,  and  may  contain 
sugar  no  longer,  although  it  might  have  done  so  during 
life. 

The  medico-legal  difficulties.  Gentlemen,  are  therefore 
very  great,  and  the  problem  is  very  difficult  to  solve. 

If  we  are  to  believe  Colin  and  Parrot,  the  quantity  of 
urine  passed  during  coma  is  diminished  to  such  a  degree 
that  Parrot  has  been  tempted  to  speak  of  '  anuria  ';  thus,  the 
diabetic  seems  to  die  at  the  moment  when  excretion  of  urine 
ceases. 

*  Cyr,  'Traits  pratique  des  Maladies  du  Foie.'     Paris,  1887. 


IN  DIABETES.  243 


Another  form  of  sudden  death  in  diabetes  has  been 
described,  due  to  syncope  or  atrophy  of  the  heart.  Two 
English  physicians,  Dickinson  and  Scott,  are  the  principal 
writers  who  have  laid  stress  on  this  form.  In  the  autopsies 
on  diabetics  that  I  have  made,  I  have  found  the  heart  fatty, 
but  never  atrophied. 


LECTURE  XL 
SUDDEN  DEATH  DUE  TO  THE  KIDNEYS. 

A.  UREMIA— AUTO-INTOXICATION. 

Gentlemen, — Death  due  to  the  kidneys  is  the  most  frequent 
form  of  sudden  death.  Let  me  say  at  once  that  the  renal 
lesion  is  not  always  the  only  factor ;  there  is  often  a  com- 
bination of  causes,  and  for  this  reason  the  mechanism  of 
this  kind  of  sudden  death  is  difficult  to  determine.  But 
from  the  point  of  view  with  which  we  are  concerned  at 
present,  it  is  necessary  to  remind  you  that  the  kidney  is  the 
great  emunctory  of  toxines  and  of  all  foreign  products  which 
pass  through  the  system,  entering  the  blood  and  being  dis- 
charged from  it  without  assimilation.  Death  supervenes 
when  poisons  manufactured  in  the  system,  or  unwholesome 
food  that  has  been  ingested,  can  no  longer  be  adequately 
removed  by  the  diseased  kidneys.  The  individual  is  there- 
fore poisoned  either  by  his  food  or  by  poisons  which  are 
generated  within  his  own  body,  i.e.,  auto-intoxication. 

When  we  study  the  kidney  in  childhood,  in  the  adult,  and 
in  old  age,  we  see  that  the  size  of  the  gland  in  proportion  to 
the  rest  of  the  body  is  not  constant.  In  the  child  the  kidney 
is  of  enormous  size,  in  the  adult  it  is  less,  and  it  is  atrophied 
in  old  age. 

Take  the  kidney  of  an  adult.  You  know  its  shape ;  you 
know  that  it  consists  of  cortex  and  medulla,  and  that  it  is 
provided  with  a  hilum,  in  which  are  the  pelvis  and  calyces 
surrounded  with  a  padding  of  fat.  In  old  age  the  hilum 
enlarges  and   becomes   loaded    with    fat,   while    the  cortex 


SUDDEN  DEATH  DUE  TO  THE  KIDNEYS  245 

shrinks,  so  that  the  senile  kidney  is  contracted  in  two  direc- 
tions. 

It  may  therefore  be  said,  from  an  anatomical  point  of 
view,  that  the  essential  part  of  the  kidney  diminishes  with 
age. 

From  the  physiological  point  of  view,  we  know  that  a  dose 
of  iodide  of  potassium  given  at  the  same  time  to  a  child,  to 
an  adult,  and  to  an  old  man,  appears  more  quickly  in  the 
urine  of  the  child  than  in  that  of  the  adult,  and  more  quickly 
in  that  of  the  adult  than  in  that  of  the  old  man. 

Ten  years  ago  I  made  the  following  experiment  in  my 
own  house.  I  took  a  young  man,  aged  20  (he  had  not  yet 
drawn  lots  for  the  conscription),  who  was  my  servant,  an 
adult,  myself  (I  was  45  years  of  age,  and  I  consider  that 
my  kidneys  were  then  those  of  an  adult),  and  my  mother, 
aged  70. 

We  each  took  15  grains  of  salicylic  acid,  dissolved  in  half 
a  bottle  of  wine  and  water,  in  the  course  of  the  day.  In  my 
servant,  the  salicylic  acid  appeared  in  the  urine  an  hour 
after  breakfast  ;  in  myself,  only  in  the  evening,  after  I  had 
drunk  all  the  half-bottle  ;  in  my  mother,  not  until  the  third 
day.  On  the  following  day  the  servant  no  longer  had  any 
salicylic  acid  in  his  urine  ;  in  myself  the  elimination  lasted 
for  four  days  ;  it  lasted  nine  days  in  my  mother.  The  gra- 
dation is  therefore  closely  related  to  age. 

An  important  fact  follows  from  this,  from  the  point  of 
view  of  poisoning  by  substances  swallowed  in  small  daily 
doses,  and  I  will  add  that  it  is  a  fact  of  which  there  is 
actual  proof.  Observe  that  my  m.other,  my  servant,  and 
myself  had  healthy  kidneys.  But  how  many  people  are 
there  whose  kidneys  are  affected  as  a  result  of  some  former 
disease,  e.g.,  of  nephritis  from  scarlet  fever,  rheumatism, 
pregnancy,  etc.  These  persons  have  kidneys  which  are  older 
than  they  themselves  are ;  their  renal  lesion  may  have  been 
completely  cured,  yet  in  spite  of  that  they  may  be  subject  to 
the  most  serious  accidents.     Let  me  give  you  an  instance  : 

A  pupil  of  the  Monge  school,  about  13  years  of  age,  was 
knocked  about  by  his  companions,  and  struck  his  loin  against 
the  corner  of  a  desk.     He  returned  home,  and  passed  blood 


246  SUDDEN  DEATH 


with  his  urine.  A  surgeon  and  I  were  called  in,  and  we 
thought  there  was  a  contusion  with  rupture  of  the  kidney. 
The  boy  got  well.  Eighteen  months  afterwards  he  suffered 
from  an  attack  of  jaundice,  which  seemed  to  be  only  simple 
catarrhal  jaundice  ;  however,  it  rapidly  assumed  the  malig- 
nant form  ;  albuminuria  appeared  on  the  seventh  day,  there 
was  almost  complete  suppression  of  urine,  and  the  boy  died. 

Remember,  then,  that  an  individual  who  has  suffered  from 
damaged  kidneys,  although  all  signs  of  the  mischief  have 
disappeared  for  a  long  time,  is  exposed  to  grave  dangers  if 
he  catches  any  infective  or  eruptive  fever.  Even  influenza 
may  be  the  cause  of  these  accidents ;  I  can  cite  two  cases 
to  you  bearing  on  the  matter. 

The  subject  of  the  first  case  was  a  deputy;  that  of  the 
second  a  hospital  physician.  They  had  both  fought  in  the 
war  of  1870-71,  one  in  the  army  of  the  Loire,  the  other  in 
Bourbaki's  army.  Both  had  suffered  during  that  period 
from  nephritis  induced  by  exposure  to  cold,  but  they  had 
completely  recovered  from  it.  They  suffered  from  influenza 
four  years  ago  ;  in  spite  of  the  mildness  of  the  influenza, 
they  showed  symptoms  of  cerebral  disturbance,  with 
anxiety,  loss  of  memory,  etc.  They  recovered;  but  these 
unusual  complications  must  be  attributed,  not  solely  to  the 
influenza,  but  to  the  fact  that  this  disease  occurred  in  per- 
sons suffering  from  renal  inadequacy. 

Here  is  another  case,  to  which  I  have  already  referred 
with  some  fulness : 

A  retail  poultry-woman  in  the  market,  who  had  a  fine 
stuffed  turkey  remaining  on  her  hands,  invited  her  relatives 
and  friends  to  come  and  help  her  eat  it ;  all  who  partook  of 
this  turkey  became  ill ;  the  stuffing,  which  was  no  longer 
very  fresh,  contained  toxic  alkaloids.  The  woman  alone, 
who  had  not  eaten  more  than  her  guests,  died,  because  she 
had  diseased,  and  therefore  inadequate,  kidneys.  She  could 
not  eliminate  the  toxic  substances  which  she  had  swallowed. 

It  is  not  necessary,  however,  that  the  substances  swallowed 
should  be  of  a  poisonous  nature.  A  journahst,  after  a  copious 
repast,  went  to  a  house  of  ill-fame  in  the  Rue  Tiquetonne ; 
he   was    already    somewhat    intoxicated ;    nevertheless,    he 


DUE  TO  THE  KIDNEYS.  247 

treated  all  the  inmates  of  the  establishment  to  champagne, 
and  finally  went  upstairs  with  one  of  them.  When  he  was 
in  bed  he  defaecated  as  he  lay  there.  The  woman  was  dis- 
gusted, and  slipped  away,  leaving  him  by  himself.  Next 
morning,  when  the  door  of  the  room  was  opened,  the  man 
was  found  lying  dead  on  the  floor  at  the  foot  of  the  bed, 
with  his  left  side  covered  with  bruises.  Naturally,  the 
superintendent  of  police  intervened ;  the  body  was  removed 
to  the  Morgue,  and  an  autopsy  was  made.  The  kidneys 
were  contracted  and  older  than  their  possessor  (he  was 
44  years  of  age).  The  champagne  that  he  had  drunk  had 
intoxicated  him  because  he  could  not  eliminate  it.  He  had 
died  of  urasmic  convulsions. 

Why  does  the  kidney  suddenly  cease  to  perform  its 
excretory  functions  ?  Because  the  organ  is  irritated  and 
congested,  and  consequently  there  is  less  urine  secreted. 
Therefore,  when  we  have  to  prescribe  a  diuretic,  we  should 
choose  one  which  is  free  from  irritating  properties. 

I  am  not  speaking  here  of  invalids,  but  of  those  persons 
who  excrete  a  few  grains  of  albumen  daily. 

The  same  is  true  of  arterio-sclerosis  and  of  cardiac 
affections ;  there  is  indeed  a  very  close  relation  between 
the  heart  and  the  kidney.  The  question  has  been  under 
discussion  for  a  long  time  in  Germany.  Traube  has  shown 
that  any  renal  mischief  will  determine  increase  of  arterial 
tension,  so  that  the  left  ventricle  becomes  hypertrophied, 
and  thus  constitutes  a  genuine  cardiac  affection. 

It   matters  little  to  us,  Gentlemen,  to  know  whether  the 
disease   of  the  heart   has  preceded  that  of  the  kidneys,  or 
vice  versa.     When  the  heart  is   diseased,   the  _kidneys    axe-       7 
-iiQilgested  ,_ajid_lhey  can_  _  no  -  longer-^alilimiate  _  the.  ^Di£erLdiilg_ 
substances  which  they  ought  to  remove  from  the  jystem-  ' 

Suppose  that  you  have  to  make  an  autopsy  on  a  person 
who  has  died  under  such  conditions.  It  is  necessary  to 
seek  for  albumen  in  the  urine.  This  search  ought  to  be 
made,  but  it  would  be  rash  to  draw  positive  conclusions 
from  it.  There  are,  indeed,  ureemic  patients  who  pass  no 
albumen.  Besides,  albumen  is  always  found  in  the  urine 
of  a  person  who  has  been  dead  48  hours.     To  assure  them- 


248  SUDDEN  DEATH 


selves  of  this  fact,  MM.  Ogier  and  Vibert  took  the  bladder 
from  a  corpse  at  the  Morgue,  emptied  it,  filled  it  with  water, 
and  hung  it  up  in  the  laboratory ;  in  a  few  hours'  time  this 
water  contained  albumen.  When  putrefaction  begins^  albu- 
men is  formed.  The  discovery  of  albumen,  therefore,  does 
not  prove  that  albumen  was  present  during  life. 

Pathological  anatomy  might  help  us  to  answer  the  ques- 
tion. Unfortunately,  when  we  make  an  autopsy  m  a  case 
of  this  kind,  we  have  too  often  to  regret  that  it  is  done  too 
late  ;  for,  in  the  first  place,  the  kidneys  occupy  a  dependent 
position  in  the  body,  and  therefore  become  infiltrated  by 
exudation  from  the  blood,  and  their  texture  is  altered 
thereby.  Death  from  uremia  ma}^  under  certain  circum- 
stances, be  attributed  to  poisoning.  Now,  medico-legal 
autopsies,  when  there  is  a  suspicion  of  poisoning,  are  most 
often  made  after  exhumation  ;  thus,  the  kidneys  are  putrefied, 
and  there  is  not  much  to  be  learnt  from  a  minute  examina- 
tion of  them. 

What  then.  Gentlemen,  are  the  forms  of  uraemia  from 
which  individuals  die  who  have  diseased  kidneys,  and  whose 
rapid  death  appears  suspicious  ? 

There  is  first  of  all  the  bronchitic  form.  The  patient  is 
suddenly  seized  with  dyspnoea  and  pulmonary  oedema,  with 
abundant  secretion  of  bronchial  froth,  which  forms  a  button 
round  the  nostrils  and  mouth  after  death,  just  as  in  bodies 
that  have  been  drowned.  He  dies  suffocated  by  bronchial 
froth.  When  we  meet  with  this  form,  the  kidneys  in  most 
cases  are  not  contracted,  but  are  the  seat  of  desquamative 
nephritis.  Sometimes  cardiac  disease  co-exists  and  in- 
tensifies the  amount  of  oedema.  Dr.  Lesser,  of  Breslau, 
who  was  formerly  Casper's  assistant,  has  paid  special 
attention  to  sudden  death.  Out  of  seventy-five  cases  which 
he  attributes  to  this  group  of  phenomena,  and  in  which  he 
finds  renal  lesions,  he  only  credits  the  kidneys  with  seven- 
teen cases  of  sudden  death,  there  being  in  these  no  disease 
of  the  heart.  For  my  own  part,  I  believe  that  the  kidneys 
play  a  much  more  considerable  part  in  the  production  of 
sudden  death  than  Lesser  assigns  to  them,  even  when 
there  is  some  cardiac  affection  present.     It  is  the  kidney 


DUE  TO  THE  KIDNEYS.  249 

which  regulates  the  amount  of  hquid  discharged  from  the 
body,  and  which  sometimes  does  not  permit  the  removal  of 
poisonous  substances  at  all. 

The  gastro-intestinal  form  is  characterized  by  coldness  of 
the  surface,  vomiting,  and  diarrhoea  ;  in  short,  by  choleraic 
phenomena.  It  gives  rise  to  the  idea  of  arsenical  poisoning. 
The  disturbance  of  the  gastro-intestinal  functions  no  longer  ' 
permits  the  food  to  undergo  the  normal  transformations  in 
the  alimentary  canal.  Dangerous  fermentations  are  set  up.  ' 
It  is  from  this  form  that  individuals  often  die,  whose 
kidneys  are  structurally  altered,  and  who  eat  tainted  or 
indigestible  food  which  they  can  no  longer  assimilate  or 
get  rid  of  in  the  normal  way. 

The  comatose  form  gives  rise  to  the  idea  of  opium-poison- 
ing.     A   magistrate  was  cross-questioning   in    his    court  a 
man  who  had  been  arrested  shortly  before.     The  man  sud-    ^ 
denly   became   comatose   and   died.     He  had   albuminuria.     / 
Coma  in  this  albuminuric  subject  was  probably  determmed    * 
by  the  mental  emotion  caused  by  his  arrest  and  examina- 
tion. 

If  this  accident  had  happened  in  a  private  house,  instead 
of  in  a  magistrate's  court  in  the  presence  of  a  magistrate, 
officials,  and  police,  all  working  in  broad  daylight,  poison- 
ing might  have  been  suspected,  and  a  medico-legal  in- 
vestigation would  have  had  to  be  made.  ^ 

The  convulsive  form  chiefly^ seizes  upon  those  persons;;  / 
jwho_drinkjto  excess^  and  especially  those  who  are  addicted 
to  certain  kinds  of  liquor,  such  as  absinthe,  arrack,  and  all 
those  which  contain  essences.  M.  Magnan  has  described 
epileptic  fits  which  are  met  with  especially  in  those 
alcoholic  subjects  whose  favourite  drinks  are  hqueurs,  etc. 
We  shall  return  to  the  subject  of  the  kidneys  of  alcoholic 
subjects  presently. 

The  fulminating  form  has  been  noticed  for  a  long  time. 
It  is  that  form  which  suddenly  strikes  an  individual,  so 
that  he  falls  down  and  dies  in  a  few  minutes  or  an  hour. 
M.  Alfred  Fournier*  published  the  first  characteristic  case. 

It   had  been  recognized  in  England  some  years  before. 
*  Alf.  Fournier,  '  Des  Formes  de  TUra^mie.'     These  d'agregation. 


1 


250  SUDDEN  DEATH 


An  individual  was  taken  ill  in  the  street,  went  to  a  chemist's 
shop,  and  received  a  draught.  He  immediately  fell  dead  on 
the  threshold  as  if  struck  by  lightning.  The  passers-by 
fancied  that  the  man  had  been  poisoned  by  the  chemist,  so 
they  set  to  work  and  smashed  everything  in  his  shop.  The 
body  was  removed  by  the  police,  and  a  judicial  autopsy 
was  ordered.  Lesions  of  Bright's  disease,  which  was  already 
well  known,  were  found  in  the  kidneys,  and  this  explained 
the  sudden  death. 

From  what  I  have  already  told  you,  Gentlemen,  do  not 
forget  that  forensic  medicine  is  more  closely  concerned., 
jvith  uraemia  than  with  any  other  cause  pf__snd.d_en,.deathj__ 
and  that  it  is  often  difficult  to  make  a  certain  diagnosis 
from  the  results  of  an  autopsy.  Remember  that  the  kidney 
no  longer  eliminates  the  substances  which  it  is  its  function 
to  excrete.  Death  happens,  therefore,  by  auto-intoxication, 
and  this  auto-intoxication  has  been  attributed  to  the  in- 
complete excretion  of  urea.  It  is  true  that  urea  is  found 
in  the  blood,  but  at  the  same  time  the  kidney  no  longer 
eliminates  ptomaines  and  leucomaines,  which  contribute  in 
a  large  measure  to  poison  the  system.  Remember  that 
certain  substances,  such  as  salicylic  acid  for  example,  taken 
in  small  doses  daily,  are  imperfectly  excreted,  and  accumu- 
late within  and  poison  the  system,  while  a  single  large  dose 
would  have  had  no  ill  effects.  Acetate  of  lead  is  another 
such  substance.  You  know  that  in  dysentery  as  much  as 
225^  grains  can  be  administered  in  one  enema  without  any 
risk  ;  but  if  one-thirtieth  part  of  this  dose  is  given  daily  for 
a  month,  symptoms  of  poisoning  will  be  produced. 

Lead-poisoning  may  induce  convulsive  or  delirious  symp- 
toms. When,  about  1864,  MM.  Ollivier,  Cornil,  Fritz,  and 
Ranvier  made  their  researches  into  lead-poisoning,  which 
they  confirmed  by  experiments  on  animals,  they  studied  the 
state  of  the  kidneys  in  this  condition  with  great  care,  and 
found  interstitial  nephritis.  The  kidney  was  no  longer  the 
perfect  filter  that  it  ought  to  be. 

Your  responsibility  in  regard  to  these  accidents  may  be 
called  in  question  under  other  circumstances.  An  individual 
may  have  albuminuria  of  which  he  may  be  ignorant.      It 


DUE  TO  THE  KIDNEYS.  251 

may  be  unattended  by  oedema  or  by  any  functional  disturb- 
ance, and  you  yourself  will  be  unaware  of  it,  unless  3'ou 
systematically  examine  the  urine  of  all  your  patients  for 
albumen. 

M.  Bouchard  has  related  this  case  :  While  he  was  acting 
for  Professor  Bouillaud  at  the  Charite  Hospital,  a  woman  was 
admitted  under  his  care  suffering  from  syphilis,  and  for  whom 
he  prescribed  mercurial  pills.  When  this  woman  had  taken 
one  pill,  she  was  seized  with  severe  stomatitis  and  terrible 
uraemic  symptoms.  M.  Bouchard  examined  the  urine,  and 
found  albumen  in  it.  The  kidneys  were  unsound,  and  thus 
the  mercury  was  not  eliminated. 

In  1877  I  was  consulted  about  an  identical  case.  The 
brother  of  one  of  my  pupils  was  a  cavalry  officer,  and  a 
student  at  the  Military  School.  This  young  soldier  was 
covered  with  boils.  I  was  invited  to  see  him,  and  I  ascer- 
tained that  he  had  no  albumen  or  sugar  in  his  urine.  Some 
days  afterwards  he  contracted  a  hard  chancre,  followed  by 
roseola,  and  after  the  administration  of  a  single  mercurial 
pill  he  suddenly  became  collapsed.  The  urine  was  examined 
at  once,  and  showed  an  enormous  proportion  of  albumen — - 
34  grains  per  ounce  of  dried  albumen.  You  wiU  find  this 
case  reported  at  length  by  M.  Descoust.* 

A  consultation  was  held,  and,  in  spite  of  my  advice,  the 
administration  of  mercury  was  prescribed  afresh.  The 
officer  had  only  taken  two  mercurial  pills,  when  he  became 
affected  with  stomatitis,  which  lasted  five  months.  The  use 
of  mercury  had  to  be  discontinued.  The  affection  of  the 
kidneys  was  cured,  however.  Three  or  four  years  after,  this 
officer  was  sent  to  Tunis,  and  there  he  contracted  typhoid 
fever  with  renal  complications,  which  caused  his  death, 
because  his  renal  filter  had  not  returned  to  its  absolutely 
normal  condition. 

Other  causes  may  lead  to  similar  results,  without  the 
kidneys  being  primarily  affected. 

When  I  was  Aran's  house-physician,  an  old  woman  who 
seemed  much  exhausted  was  admitted  under  my  care.     She 

*  Descoust,  '  De  I'Albuminurie  survenant  dans  le  Cours  des  Accidents 
secondaires  de  la  Syphilis.'     These,  Paris,  1878. 


252  SUDDEN  DEATH 


became  comatose  one  evening,  and  died  in  the  night.  When  I 
reported  the  fact  to  my  chief  the  next  morning,  he  said  to  me, 
'  That  woman  had  cancer  of  the  uterus,'  This  proved  to  be 
the  case.  Cancer  of  the  cervix  uteri  may  invade  the  fundus 
of  the  bladder.  When  it  reaches  a  certain  size,  it  blocks  up  the 
orifices  of  the  ureters,  and  thus  causes  retention  of  the  urine 
in  the  kidneys  and  their  ducts.  Evacuation  of  fluids  which 
ought  to  be  excreted  is  impossible,  and  may  sometimes  lead 
to  hydronephrosis  and  urasmic  poisoning.  The  same  com- 
plications may  follow  stricture  of  the  urethra,  prostatitis, 
stone  in  the  bladder,  etc. 

B.  GOUT. 

I  think  I  ought  to  place  sudden  death  in  gout  by  the  side 
of  sudden  death  from  diabetes  and  of  that  from  renal  com- 
plications. 

Old  authors  used  to  say  that  sudden  death  in  gout  was 
due  to  visceral  metastases. 

Since  Garrod  clearly  established  the  distinction  between 
rheumatism  and  gout,  English  authors  have  observed  more 
and  more  attentively  the  state  of  the  kidneys  in  the  autopsies 
they  perform,  and  they  have  described  the  '  gouty  kidney,' 
which  they  sometimes  confound  with  the  senile  kidney. 
English  physicians  have  more  opportunities  than  we  have  of 
studying  gout.  The  consumption  of  beer,  and  especially  of 
porter,  seems  to  explain  its  frequency.  In  France  we  scarcely 
ever  see  the  phenomena  of  gout  in  hospitals,  except  in 
association  with  lead-poisoning,  and  outside  the  hospital  we 
onl}^  see  it  among  the  richest  of  our  patients. 

Gouty  metastases,  of  which  the  old  authors  speak,  are  of 
different  sorts.  There  is  first  of  all  serous  apoplexy,  i.e., 
abundant  serous  effusion  into  the  meshes  of  the  pia  mater 
and  into  the  ventricles.  Then  there  is  gout  rising  into  the 
lungs.  This  consists  of  symptoms  analogous  to  those  which 
I  described  to  you  under  the  heading  of  pulmonary  oedema 
and  capillary  bronchitis.  The  individual  dies,  suffocated  by 
his  bronchial  froth,  as  Piorry  said.  Finally  w^e  have  choleraic 
intestinal  symptoms.  This  form  is  one  of  the  classical  mani- 
festations of  ursemia. 


DUE  TO  THE  KIDNEYS.  253 

Gentlemen,  in  passing  under  review  the  150  cases  of  gouty 
metastasis  that  I  have  been  able  to  collect  from  the  writings 
of  authors,  I  have  nearly  always  found  that  some  renal  lesion 
was  present.  I  do  not  venture  to  make  the  unqualified 
assertion  that  sudden  death  in  gout  always  has  a  renal 
origin  ;  I  am  strongly  inclined  to  believe  it,  but  I  have  not 
myself  seen  enough  cases  of  the  kind — a  dozen  at  most — 
and  my  experience  has  not  been  long  enough  to  make  me 
sure  of  it. 

In  what  manner  may  it  be  necessary  for  the  medical  jurist 
to  intervene  ?  x\ll  physicians,  Trousseau  especially,  who 
have  seen  much  of  gout,  have  said  :  '  You  should  never  try 
to  arrest  an  attack  of  gout  ;  on  the  contrary,  you  should  try 
to  prevent  a  retrocession.'  Gouty  patients,  naturally,  are  not 
of  that  opinion.  A  gouty  attack — and  it  has  not  varied 
since  Sydenham  described  it  in  such  a  masterly  way — is  very 
painful  and  very  hard  to  bear.  So  what  do  the  gouty 
patients  do  ?  Their  physician  does  not  relieve  them,  there- 
fore they  fly  to  quacks ;  they  have  recourse  to  secret 
remedies,  or  what  profess  to  be  such.  Nov/,  in  this  country 
the  secret  remedy  for  gout  is  nothing  else  than  colchicum, 
and  it  must  be  admitted  that  it  is  effectual.  Fatal  cases  of 
gout  have  nearly  alwaj^s  been  treated  by  some  medicine,  the 
basis  of  which  is  colchicum — the  'liqueur  de  Laville,'  or 
something  of  the  sort.  Colchicum  may  act  in  two  different 
ways  :  it  either  increases  the  quantity  of  urine  excreted,  or 
else  it  lessens  it  by  causing  congestion  of  the  kidneys.  If 
the  quantity  of  urine  is  increased,  the  treatment  is  favour- 
able ;  if  it  is  diminished,  it  is  dangerous. 

You  know.  Gentlemen,  that  a  congested  organ  does  not 
perform  its  functions  properly  ;  when  an  individual  works  at 
his  desk  with  attention  and  application,  and  especially  if  his 
shirt-collar  is  tight,  his  brain  becomes  congested,  his  face 
becomes  purple,  and  the  activity  of  his  brain  is  not  increased, 
but  diminished. 

When  in  any  organ  the  exit  of  blood  is  more  difficult 
than  its  entry,  the  organ  becomes  turgid  and  congested,  and 
its  functions  are  impeded.  It  is  altogether  different  when 
an  organ  is  in  full  activity,  when  the  blood  flows  to  it  freely 


254  SUDDEN  DEATH 


and  no  obstacle  hinders  its  return.  It  is  the  same  with  the 
brain  as  with  the  sahvary  glands  (CI.  Bernard),  When  the 
kidney  is  working  actively,  physiology  has  taught  us  that 
the  blood  of  the  renal  veins  is  red.  But  repeat  the  experi- 
ment in  animals  in  which  you  have  produced  congestion  of 
the  kidneys  by  obstructing  the  renal  veins — by  a  loose  liga- 
ture, for  example  ;  then  the  blood  of  the  renal  veins  is  black. 
The  same  thing  happens  in  the  kidneys  of  gouty  persons; 
when  renal  congestion  is  produced  by  the  ingestion  of  a 
substance  which  irritates  the  kidneys,  the  secretion  of 
urine  is  diminished,  and  there  is  retention  of  products  which 
ought  to  be  excreted. 

Moreover,  a  gouty  man  is  a  frail  creature.  He  often  has 
sclerosis  of  the  arteries  and  of  the  heart ;  he  has  lesions  of 
the  liver  ;  if  some  disturbance  of  the  circulation  should 
supervene,  his  condition  immediately  becomes  grave.  As 
long  as  the  kidneys  are  working  properly,  his  health  is  good ; 
but  as  soon  as  the  functions  of  the  kidney  are  checked, 
whether  by  atrophy  or  by  congestion,  he  is  in  danger. 


LECTURE  XII. 
SUDDEN  DEATH  IN  ALCOHOLISM. 

Gentlemen, — Alcoholism  has  already  engaged  our  atten- 
tion on  various  occasions  in  the  course  of  these  lectures  ; 
nevertheless,  it  is  necessary  to  describe  certain  phases  of  it 
with  greater  precision. 

Alcoholism  presents  itself  in  several  forms.  In  the  first 
degree  there  is  the  individual  v/ho  has  only  been  guilty  of  a 
single  excess,  which  is  fatal  only  in  exceptional  cases  ;  such 
is  the  individual  who  is  picked  up  dead  drunk.  Then  comes 
delirium  tremens,  and  lastly  chronic  alcoholism. 

A.  DRUNKENNESS. 

How  does  death  take  place  in  a  fit  of  drunkenness,  the 
consequence  of  a  single  excess  ?  It  is  by  the  body  becoming 
cold.  You  know  that  in  slight  degrees  of  intoxication  the 
face  becomes  flushed  and  turgid  ;  when  drunkenness  is  more 
profound,  the  capillaries  of  the  surface  dilate,  and  a  peripheral 
vaso-motor  paralysis  takes  place.  Consequently  the  indi- 
vidual radiates  a  large  amount  of  heat.  When  a  man  who 
has  been  found  dead  drunk  is  taken  to  the  hospital,  the 
thermometer  in  the  rectum  shows  that  the  central  tempera- 
ture has  fallen  to  75"2°  F.  Two  cases  of  this  class  have  been 
recorded — one  by  M.  Laborde,  the  other  by  M.  Bourneville. 

Is  this  the  only  mode  of  cooling  to  which  people  in  the 
state  of  drunkenness  are  exposed  ?  I  do  not  think  so. 
Magnus  Huss,  a  Danish  physician,  demonstrated  the  pre- 
sence of  little  globules  of  fat  in  the  blood  of  individuals 
who   died  while  drunk.     I   myself  observed  in   1871,  when 


J56  SUDDEN  DEATH 


making  experiments  on  the  blood  of  persons  suffering  from 
small-pox,  scarlet  fever,  and  delirium  tremens,  that  the  blood 
corpuscles  lost  an  appreciable  amount  of  their  oxidizability  ; 
as  they  no  longer  retain  oxygen,  they  cannot  distribute  to 
the  various  parts  of  the  body  the  gas  which  maintains  com- 
bustion, regularity  of  respiration,  and  calorification. 

In  former  times  a  method  of  treatment  was  adopted 
towards  drunkards  which  recent  researches  have  justified. 
They  placed  the  drunkard  on  a  dung-hill  and  covered  him 
up  ;  as  the  dung-heap  is  warm,  it  counteracted  the  tendency 
of  the  drunken  man  to  become  cold. 

This  method  still  prevails  in  Brittany  and  Normandy  ; 
sometimes  persons  who  are  dead  drunk  are  placed  in  a 
baker's  oven  ;  but  the  effect  of  this  is  a  matter  of  chance, 
for  the  oven  may  be  too  hot  or  may  have  already  become 
cold.  When  you  read  descriptions  of  the  anatomical  lesions 
which  the  organs  present  in  the  bodies  of  those  who  have 
died  in  a  state  of  intoxication,  you  will  be  told  that  the 
stomach  is  contracted  with  prominent  ridges,  and  that  spots 
or  ecchymoses  are  scattered  over  the  mucous  membrane. 
Only  a  short  time  ago  I  had  to  make  an  autopsy  on  a  girl 
who  had  committed  suicide  by  swallowing  absinthe  ;  a  paper 
that  was  found  by  the  side  of  the  girl  left  no  doubt  that  the 
case  was  one  of  suicide. 

That  girl  had  taken  about  25  oz.  of  absinthe.  We 
thought  at  the  time  that  we  should  be  sure  to  find  in  her 
viscera  the  characteristic  signs  of  acute  alcoholic  intoxica- 
tion ;  we  could  not,  however,  detect  the  smell  of  alcohol  or 
of  absinthe  :  the  stomach  was  empty  and  not  shrunken  ; 
the  mucous  membrane  was  normal,  and  the  rest  of  the 
viscera  were  perfectly  sound.  If  this  girl  had  not  given 
evidence,  by  her  writing,  of  her  determination  to  commit 
suicide,  and  if  a  bottle  holding  if  pints  of  absinthe  had  not 
been  found  by  her  side,  do  you  think  that  an  autopsy  would 
have  afforded  an  explanation  that  would  satisfy  the  law  ? 
Not  at  all.  Remember,  then,  that  death  from  ingestion  of 
alcohol  may  leave  no  mark  on  the  body  that  will  guide  you 
in  your  search,  and  that  will  reveal  to  you  the  mode  of  death 
in  the  case  you  are  examining. 


IN  ALCOHOLISM.  257 


B.  DELIRIUM  TREMENS. 

The  second  form  of  alcoholism  is  characterized  by 
delirium  tremens.  It  is  familiar  to  you,  and  I  will  not 
describe  it  at  length.  A  long  while  ago  a  distinguished 
physiologist  demonstrated  how  frail  a  being  Hercules  may 
be  when  drunk.  You  know  that  this  delirium  is  often 
accompanied  by  acts  of  violence  ;  you  know  that  a  large 
number  of  alcoholic  subjects  of  this  class  have  to  be  con- 
lined  in  a  madhouse.  The  superintendent  of  the  asylum 
does  not  fail  to  warn  those  who  bring  the  patient  that  the 
latter  is  in  a  condition  which  exposes  him  to  great  danger, 
even  from  the  delirium  itself,  and  that  he  may  die  suddenly. 
In  fact,  it  sometimes  happens  that  one  of  these  patients 
dies  in  a  paroxysm  of  excitement  the  very  day  after  his 
admission  into  the  asylum.  The  superintendent  and  at- 
tendants of  the  asylum  may  be  held  responsible,  and  you 
should  know  that  in  the  immense  majority  of  cases  they  are 
quite  free  from  blame. 

C.  CHRONIC  ALCOHOLISM. 

I  have  already  told  you  that  chronic  alcoholism,  i.e.,  the 
third  stage  of  alcoholism,  has  the  power  of  making  acute 
diseases  run  their  course  in  a  latent  manner  ;  this  applies  to 
cases  of  pneumonia,  meningitis,  etc.,  of  which  I  have  cited 
examples  to  you,  so  that  I  need  not  return  to  them.  Alco- 
holism, moreover,  creates  lesions  in  every  organ,  and  the 
subject  of  it  is  thus  exposed  to  the  danger  of  sudden  death 
in  every  form  which  may,  in  fact,  result  from  lesions  of  these 
organs. 

This  is  not  all :  sudden  death  often  overtakes  alcoholic 
persons  who  have  recovered  from  their  primary  disease,  and 
have  become  convalescent ;  is  this  because  the  myocardium 
is  affected  ?  The  lesions  from  which  alcoholic  subjects 
suffer  are  so  numerous  and  of  such  variety  that  it  is  difficult 
to  enumerate  them.  Sudden  death  occurring  in  them  is 
attributable,  above  all,  to  fibroid  degeneration  of  the  heart, 
kidneys  or  liver. 

The  same  phenomena  are  wont  to  appear  as  a  sequence 

17 


-58  SUDDEN  DEATH 


of  injuries  or  of  surgical  operations.  Dupuytren  was  accus- 
tomed to  say  that  he  did  not  lose  any  of  his  operation- 
cases,  except  those  who  were  attacked  by  delirium  tremens. 
Dupuytren  practised  at  a  period,  Gentlemen,  when  the 
classification  of  diseases  was  less  precise  than  it  is  now,  and 
when  purulent  infection  was  not  uncommon.  I  am  inclined 
to  believe  that  among  these  cases  of  '  delirium  tremens ' 
were  included  many  cases  of  septicaemia. 

D.  MEDICO-LEGAL  INTERVENTION. 

Two  important  points  still  await  our  attention  :  the  inter- 
vention of  the  medical  expert  in  alcoholism  constitutes  one 
of  the  longest  chapters  in  medical  jurisprudence.  The 
individual  whose  condition  is  to  be  investigated  may  be 
either  the  author  or  the  victim  of  a  criminal  act  ;  he  may 
be  a  culprit  in  such  a  way  as  this  :  You  have  all  seen  tipsy 
people ;  you  know  that  a  person  who  has  taken  rather  too 
much  is  sometimes  amusing  for  a  time  ;  he  says  whatever 
comes  into  his  head,  he  becomes  confidential,  and,  however 
stupid  he  may  be,  his  sallies  are  often  very  comical.  But 
he  does  not  always  content  himself  with  exuberance  of 
language ;  in  an  individual  under  the  influence  of  alcohol 
there  is  no  barrier  between  the  idea  and  the  act ;  there  is 
no  room  for  reflexion.  He  sees  a  ditch  and  leaps  over  it, 
without  thinking  whether  he  will  clear  it  or  fall  in.  The 
idea  of  hanging  himself  enters  his  head,  and  he  does  hang 
himself,  without  knowing  why,  and  this  idea  is  so  firmly 
rooted  in  his  mind  that  nothing  can  erase  it. 

Lasegue  has  reported  the  following  suggestive  case,  bear- 
ing on  this  subject : 

A  sentinel  heard  a  noise  one  night  by  the  side  of  his  box. 
He  wished  to  ascertain  where  the  noise  came  from,  and 
saw  a  drunken  woman  who  had  fastened  a  twisted  cord  to 
the  window  of  the  sentry-box  and  was  going  to  hang  her- 
self. The  soldier  ran  after  her,  but  saw  that  she  stopped  a 
little  way  off  in  order  to  make  a  fresh  attempt.  He  called 
the  attention  of  the  guard  to  her,  and  the  woman's  attempt 
was  thwarted  again,  and  her  life  was  saved ;  but  she 
managed  to  carry  out  her  project  by  turning  round  a  corner 
of  the  street,  where  the  sentinel  could  not  see  her. 


IN  ALCOHOLISM.  259 


Nearly  thirty  years  ago  a  wine-merchant's  porter,  who 
was  an  alcoholic  subject,  threw  himself  from  the  top  of  the 
Bastille  column ;  at  that  time  the  railings  which  surround 
the  monument  were  undergoing  repairs,  the  weather-cocks 
at  the  top  were  being  gilded,  and  a  large  well-stretched 
awning  had  been  put  up  all  round  the  base  of  the  column. 
The  man  fell  on  to  this  awning,  rebounded,  alighted  on  the 
ground,  and  walked  away  without  having  sustained  any 
injury.  But  the  police  ran  after  him  and  arrested  him  ;  and 
when  taken  before  the  superintendent  he  stated,  now  that 
he  was  sober,  that  he  had  no  motive  for  committing  suicide, 
and  that  the  idea  of  throwing  himself  down  had  come  into 
his  head  suddenly  while  he  was  on  the  top  of  the  column. 
This  man  afterwards  became  a  hospital  porter,  and  has 
acted  as  porter  in  the  post-mortem  theatre  for  15  years,  yet 
the  idea  of  suicide  has  never  returned,  and  he  has  never 
been  able  to  explain  why  he  ever  wanted  to  commit  the  act. 

The  alcoholic  subject  does  not  make  attempts  on  his  own 
life  merely.  He  is  a  dangerous  man  both  to  his  relatives 
and  to  his  neighbours.  He  sleeps  badly  ;  he  imagines  that 
he  sees  glittering  objects,  and  fancies  that  he  is  surrounded 
by  animals,  which  make  offensive  remarks  and  insult  him  ; 
he  has  hallucinations  of  touch,  and  believes  that  he  is  ex- 
posed to  violence  of  greater  or  less  severity  ;  in  short,  he 
has  hallucinations  of  sight,  touch,  and  hearing. 

Allow  me  to  remind  you  of  a  certain  butcher-bo}'  who 
imagined  one  night  that  his  wife  struck  him  on  the  head 
with  a  boot ;  he  got  up,  took  his  knife  and  cut  her  throat ; 
then  he  chopped  her  in  half,  as  if  she  were  a  carcass  of 
veal  or  pork,  and  set  to  work  to  cut  her  body  into  joints  as 
if  he  were  preparing  meat  for  sale.  He  was  arrested,  and 
confined  in  Mazas  Gaol,  and  at  the  end  of  three  weeks 
his  alcoholic  delirium  had  entirely  disappeared. 

This  man  was  instigated  by  an  impulse  whose  direction 
was  determined  by  his  professional  habits ;  the  murderer 
literally  butchered  his  victim,  and  seemed  to  act  in  a  blind 
attack  of  epileptic  fury.  Individuals  who  commit  crimes  of 
this  sort  are  those  who  display  the  greatest  propensity  to 
commit  suicide. 


26o  SUDDEN  DEATH 


Statistics  prove  that  the  number  of  crimes  and  suicides 
is  in  proportion  to  the  consumption  of  alcohol.  The  curve 
which  indicates  the  consumption  of  alcohol  in  each  depart- 
ment is  identical  with  that  of  suicides  and  crimes  against 
the  person.  The  consumption  of  alcohol  is  ten  times  as 
large  as  it  was  twenty  years  ago ;  the  number  of  suicides 
has  increased  to  the  same  extent. 

Gentlemen,  if,  disregarding  the  interests  of  society,  we 
answer  the  question  which  is  put  to  us,  whether  or  not  the 
man  who  commits  such  a  crime  is  or  is  not  conscious  of 
what  he  is  doing,  and  responsible  for  his  actions,  we  might  be 
tempted  to  say,  when  brought  face  to  face  with  a  crime  com- 
mitted by  an  alcoholic  subject :  '  This  man  is  not  responsible, 
because  he  delivered  the  blow  during  an  attack  of  alcoholic 
insanity.' 

Well,  Gentlemen,  these  words  have  never  crossed  my  lips 
in  the  court  of  assizes.  I  cannot  admit  the  irresponsibility 
of  persons  under  the  influence  of  alcoholic  excess  ;  it  is  not 
the  same  thing  as  insanity.  He  has  become  enraged  because 
of  his  vicious  habits,  and  he  is  at  least  responsible  for  those 
preliminary  acts  which  led  to  the  perpetration  of  the  crime. 
A  madman,  a  poor  lunatic,  is  not  responsible  ;  but  a  man 
under  the  influence  of  alcohol,  a  man  who  knows  that  his 
drunken  habits  will  by  degrees  bring  him  into  such  a  condi- 
tion that  he  may  kill  his  fellows,  is  responsible  for  his 
actions. 

Moreover,  the  question  which  the  Code  lays  before  us  is 
badly  worded.  We  know  how  dangerous  persons  suffering 
from  alcoholic  delirium  are.  If  we  state  that  they  are  not 
responsible,  they  will  be  set  at  liberty.  Now,  the  more  a 
man  is  addicted  to  alcohol,  the  more  dangerous  he  is  ;  but 
he  would  be  deemed  irresponsible  all  the  more,  and,  therefore, 
the  more  dangerous  an  alcoholic  subject  is,  the  more  surely 
would  he  be  set  at  liberty. 

Here  is  a  typical  example  : 

An  individual,  after  a  good  luncheon  at  a  restaurant  in  the 
Cannebiere  at  Marseilles,  was  sitting  on  the  terrace  of  a  cafe 
amusing  himself  with  shooting  at  the  passers-by  with  a 
revolver.      He  was  arrested,  but  was  declared  irresponsible. 


IN  ALCOHOLISM.  261 


and  was  confined  in  a  lunatic  asylum.  In  a  few  months  his 
alcohoHc  insanity  had  passed  off;  he  was  discharged,  and 
went  to  Toulon,  and  again  after  luncheon  fired  at  the  passers- 
by,  wounding  one  or  two  of  them.  He  was  again  arrested 
and  sent  to  an  asylum.  This  time  he  remained  eleven 
months  in  an  asylum  in  the  department  of  Vaucluse  ;  at  the 
end  of  this  time,  as  he  appeared  to  be  in  perfect  bodily  and 
mental  health,  he  was  restored  to  liberty.  He  took  the  train 
to  Dijon,  and  there,  after  luncheon,  tried  to  strangle  the 
station-master  on  the  platform  of  the  station.  He  was  taken 
back  to  the  asylum,  and  at  the  end  of  three  years  the  same 
scruples  took  possession  of  the  superintendent,  and  he 
thought  that  he  had  no  right  to  keep  a  man  shut  up  who  no 
longer  had  anything  the  matter  with  him,  and  discharged 
him. 

This  time  he  went  to  Paris,  and  after  a  good  luncheon 
there  he  again  openly  fired  at  the  passers-by  near  the  Odeon 
omnibus  station  in  the  Boulevard  des  Italiens,  and  wounded 
several  persons  more  or  less  dangerously.  The  unfortunate 
man  was  sent  to  an  asylum  for  a  fourth  time,  and  has  now 
been  in  confinement  about  three  years.  What  will  happen 
when  he  is  again  discharged  ? 

You  see  that  the  medical  jurist  has  a  somewhat  delicate 
duty  to  discharge  in  deciding  as  to  the  responsibility  of 
alcoholic  subjects  and  lunatics. 

Medico-legal  intervention  is  called  for  equally  on  behalf  of 
the  victim  of  the  drunkard.  Works  on  forensic  medicine 
are  full  of  such  cases  as  the  following  : 

Some  men  were  drinking  at  a  tavern,  when  a  discussion 
arose,  which  became  heated  and  led  to  a  quarrel,  and  at  last 
one  of  the  drinkers  gave  another  a  box  on  the  ear.  The 
latter  did  not  return  the  blow,  but  withdrew  to  another  table, 
put  his  head  on  his  arm  as  if  he  were  going  to  sleep,  and 
remained  motionless.  The  proprietor  of  the  tavern  heard 
him  snoring,  but  took  little  notice  of  him  at  first,  thinking 
that  the  man  was  sleeping  himself  sober.  But  after  a  while 
he  went  up  to  him  and  shook  him,  in  order  to  wake  him ; 
the  man  was  dead.  At  the  autopsy,  meningeal  haemorrhage 
was  found,  covering  the  surface  of  the  brain  ;  the  skull  was 


262  SUDDEN  DEATH. 


not  fractured,  and  the  brain  itself  was  normal.  x\ll  the  other 
organs  of  the  body  were  healthy. 

Tardieu  has  reported  the  following  case  :  A  father  and  son 
were  quarrelling  ;  at  the  end  of  the  dispute  the  father  gave 
his  son  a  slight  box  on  the  ear  ;  the  latter  fell  down,  and  died 
a  few  hours  after  from  meningeal  haemorrhage. 

The  gravity  of  the  lesions  in  these  cases  depends  on  the 
victim,  not  on  the  culprit ;  the  blows  exchanged  are  actually 
insignificant.  The  medical  jurist  should  lay  stress  in  his 
evidence  on  the  slight  nature  of  the  injury,  and  explain 
that  the  same  blow  would  not  have  been  followed  by 
any  disastrous  results  in  a  person  who  was  not  addicted 
to  drink. 

I  could  multiply  such  cases  and  examples  ;  I  will  only 
remind  you  that  alcoholic  subjects  recover  very  badly  from 
surgical  operations,  as  M.  Verneuil  has  shown,*  and  that 
erysipelas  is  a  frequent  and  dangerous  complication  of  wounds 
in  them. 

In  the  kitchen  of  a  restaurant  in  one  of  the  boulevards, 
the  plate-washer  and  a  scullion  were  quarrelling.  They 
became  more  angry,  and  the  scullion  threw  a  plate  at  the 
plate-washer's  head  ;  the  plate  did  not  break,  but  the  plate- 
washer  received  a  small  superficial  wound  on  his  forehead. 
He  was  taken  to  a  druggist,  who  gave  him  a  '  vulnerary  ' 
draught,  and  he  then  took  several  nips  of  spirits  to  steady 
his  nerves.  Two  days  afterwards  erysipelas  set  in,  and  he 
died.  The  little  sculhon  was  in  great  measure  responsible, 
you  see.  A  medico-legal  autopsy  on  the  plate-washer's  body 
was  ordered  ;  we  learnt  thereby  that  the  kidneys  were  con- 
tracted, and  that  the  liver  was  in  the  condition  of  classical 
cirrhosis.  It  is  evident  that  the  blow  caused  by  the  plate 
would  not  have  caused  a  fatal  result  in  a  person  not  addicted 
to  alcoholic  excess.  The  culpability  of  the  little  scullion  was 
therefore  much  diminished. 

*  Verneuil,  '  De  la  Gravitd  des  Lesions  traumatiques  et  des  Operations 
chirurgicales  chez  les  Alcooliques.'     Paris,  1871. 


LECTURE  XIII. 

SUDDEN  DEATH  IN  CHILDREN. 

Gentlemen, — Sudden  death  in  children  is  different,  as 
regards  pathogeny,  from  that  which  we  have  studied  in  its 
various  forms  in  adults.  The  predominant  feature  is  the  readi- 
ness with  which,  in  children,  extremely  violent  attacks  of 
congestion  are  brought  on,  which  may  be  accompanied  by 
certain  reflex  actions,  owing  to  the  excitability  of  the  nervous 
centres. 

However,  I  think  it  would  serve  no  useful  purpose  to 
recapitulate,  from  the  point  of  view  of  sudden  death  in 
children,  all  the  diseases  and  disorders  which  we  have 
studied  together  one  after  the  other  when  we  were  engaged 
with  sudden  and  suspicious  death  in  the  adult. 

I  shall  content  myself  with  laying  before  you  the  principal 
factors,  and  with  pointing  out  their  dominant  features. 

Sudden  death  is  of  frequent  occurrence  in  children.  West 
states  that,  out  of  627  cases  of  sudden  death  dealt  with  by 
the  London  police  in  1854,  272  were  those  of  children  under 
the  age  of  five  years,  and  126  of  these  were  under  one  year. 
Sudden  death  in  children  is  usually  due  to  one  of  five 
principal  causes,  viz.,  syncope,  convulsions,  asphyxia,  pul- 
monary congestion,  and  intestinal  troubles. 

A.  SYNCOPE. 

Before  going  further  into  the  study  of  these  cases,  allow 
me.  Gentlemen,  briefly  to  elucidate  a  certain  point  which 
has  sometimes  led  to  unfavourable  conclusions  being  drawn, 


264  SUDDEN  DEATH 


and  has  given  rise  to  the  suspicion  that  death  was  due  to  foul 
play.  I  refer  to  syncope.  Syncope  is  common  in  children  ; 
should  it  be  attributed  to  a  violent  pain,  to  reflex  action,  or 
to  inhibition  ? 

Devergie,  Rilliet,  and  Barthez  were  of  opinion  that 
syncope  was  a  frequent  cause  of  sudden  death  in  children. 
Barthez  cites  several  such  cases  happening  at  the  age  of 
six  or  seven  months — Devergie  at  the  age  of  one  year. 

This  kind  of  death  may  be  due  to  some  cardiac  affection, 
which  may  be  present  in  a  young  child  even  at  birth,  and 
may  be  due  to  patency  of  the  foramen  ovale  or  of  the  ductus 
arteriosus,  or  to  a  communication  between  the  two  ventricles, 
etc.  These  cases  are  more  frequent  than  those  due  to 
inflammatory  mischief.  But  fatal  syncope  may  take  place 
in  children  quite  apart  from  all  lesion  or  malformation  of 
the  heart,  and  it  is  far  from  being  rare. 

B.  CONVULSIONS. 

It  is  not  uncommon  for  children  to  die  in  convulsions. 
In  former  times,  Gentlemen,  physicians  as  well  as  the 
public  unanimously  believed  that  convulsions  were  of 
cerebral  origin,  and  therefore  regarded  them  as  extremely 
serious.  Trousseau  headed  a  reaction  against  this  belief, 
and  did  not  admit  that  convulsions  were  so  very  dangerous. 

Gentlemen,  a  child  in  convulsions  is  always  in  danger. 
Convulsions  may  be  due  to  various  causes ;  sometimes  they 
are  caused  by  some  lesion  of  the  brain,  such  as  haemorrhage, 
softening,  tumours,  or  large  masses  of  tubercle,  as  in  a  case 
recorded  by  Parrot.  These  cases  appear  all  the  more 
suspicious  because  children  at  that  early  age  are  not 
expected  to  suffer  from  diseases  of  the  kind. 

One  of  the  most  frequent  causes  of  death  at  this  age  is 
congenital  syphilis,  which  may  produce  vascular  lesions 
simulating  hasmorrhage  or  meningitis,  and  which  may  lead 
to  sudden  death.  Sometimes  caries  of  the  bones  and  peri- 
or  end-arteritis  are  found  post-mortem  in  such  cases. 

Another  cause  is  meningeal  hasmorrhage.  This  is  more 
often  met  with  in  children  at  the  period  of  dentition.     At 


IN  CHILDREN.  265 


this  time  congestive  attacks  may  take  place,  including 
lesions  of  the  parietal  arachnoid,  which  becomes  vascular. 
The  little  vessels  newly  formed  therein  may  burst,  and  sudden 
death  follows,  due  to  meningeal  hsemorrhage. 

When  you  are  called  to  attend  a  child  in  a  fit  of  con- 
vulsions, ascertain  first  of  all  if  it  is  feverish. 

If  pyrexia  is  present,  the  case  is  probably  one  of  the 
exanthemata  in  its  initial  stage.  In  children,  convulsions  are 
the  equivalent  of  a  rigor  in  the  adult.  Sydenham  observed 
that  convulsions  at  the  commencement  of  an  eruptive  fever 
are  of  little  importance.  It  is  quite  the  reverse  when  they 
occur  at  the  end  of  the  eruption. 

If  the  child  is  not  feverish,  you  may  confidently  say  that 
the  cause  is  situated  between  the  lips  and  the  anus.  Nine 
times  out  of  ten,  convulsions  are  due  to  the  process  of  den- 
tition, indigestion,  constipation,  diarrhoea,  or  a  collection  of 
worms  in  the  intestines.  In  ninety-nine  persons  out  of  a 
hundred  affected  by  tapeworm,  there  will  be  no  nervous 
symptoms,  but  in  the  hundredth  such  symptoms  will  be 
present.  Children  are  always  in  this  exceptional  condition. 
They  are  strongly  predisposed  to  suffer  from  convulsions 
when  their  alimentary  canal  is  out  of  order.  These  con- 
vulsions are  never  quite  free  from  danger,  so  give  your 
opinion  guardedly.  Through  omitting  to  do  so,  I  once 
put  myself  into  rather  an  awkward  position,  as  I  will  tell 
you  : 

When  I  was  a  young  doctor,  I  was  called  in  to  a  child  in 
convulsions.  As  my  mind  was  deeply  imbued  with  the 
teachings  of  my  masters.  Trousseau  especially,  I  reassured 
the  parents,  telling  them  that  it  was  an  everyday  occurrence, 
and  that  there  was  no  danger.  Before  I  had  finished  speak- 
ing the  child  died. 

The  truth,  Gentlemen,  is  neither  on  the  side  of  Trousseau, 
who  underrated  the  gravity  of  convulsions,  nor  on  the  side  of 
the  physicians  of  the  last  century,  who  overrated  it.  Re- 
member that  an  accident  of  this  kind  is  not  necessarily 
fatal,  but  at  any  rate  do  not  regard  it  as  trivial,  and  mind 
that  you  never  neglect  to  attend  to  the  state  of  dentition  and 
of  the  alimentary  canal. 


266  SUDDEN  DEATH 


C.  ASPHYXIA. 

I  come  now  to  the  study  of  sudden  death  due  to 
asphyxia.  Let  us  first  consider  the  phenomena  which 
nurses  call  '  inward  convulsions/  Nurses  are  not  altogether 
wrong,  although  these  convulsions  have  a  different  origin 
from  those  which  we  lately  discussed.  '  Inward  convulsion  ' 
most  commonly  implies  spasm  of  the  glottis,  due  to  laryngeal 
irritation,  or  stridulous  laryngitis,  such  as  may  take  place  in 
the  course  of  measles,  bronchitis,  or  a  common  cold. 

Stridulous  laryngitis  presents  this  characteristic  feature, 
viz.,  that  the  stridulous  attacks  always  take  place  between 
the  hours  of  lo  p.m.  and  4  a.m.  These  spasms  (for  no  other 
name  can  be  applied  to  the  symptom)  are  due  to  slight 
injHammation  of  the  mucous  membrane  of  the  larynx.  Every 
form  of  laryngeal  inflammation  may  give  rise  to  spasm  of 
the  glottis.  Croup  is  one  form.  When  we  make  an  autopsy 
on  a  child  who  has  died  of  croup,  we  often  find  only  thin 
membranes  no  thicker  than  paper,  which  are  quite  insuffi- 
cient to  block  the  lumen  of  the  trachea  and  larynx ;  but  the 
inflammation  of  the  mucous  membrane  has  induced  spasms 
which  contributed  largely  to  diminish  the  entry  of  air  into 
the  bronchi,  and  led  to  suffocation.* 

These  spasmodic  attacks  are  usually  easily  cured,  except 
in  very  young  children  and  in  those  suffering  from  diph- 
theria. 

A  special  form  of  asthma  used  to  be  described,  viz., 
'  thymic  asthma,'  to  which  Millar  attached  his  name.  Then 
the  existence  of  the  disease  was  forgotten,  and  it  has  been 
brought  to  light  again  within  the  last  few  months.  A  few 
isolated  instances  had,  however,  attracted  attention  in  the 
interval.  Some  years  ago,  as  I  was  making  an  autopsy  on  a 
child  3  or  3I  months  old,  which  was  supposed  to  have  been 
suffocated  by  its  mother,  I  found  the  thymus  very  much 
hypertrophied.  Normally,  according  to  Sappey's  observa- 
tions, the  thymus  weighs  go  to  120  grains,  and  measures 
2  inches  in  length,  4  inch  in  breadth,  and  f  inch  in  thickness. 
The  thymus  in  the  case  of  which   I  am  speaking  weighed 

*  In  English  text-books  of  medicine  it  is  too  often  omitted  that  laryn- 
gismus stridulus  may  be  the  cause  of  sudden  death  in  infants. — Tr. 


IN  CHILDREN.  267 


360  grains,  and  measured  3I  inches  in  length,  1}  inches  in 
breadth,  and  i  inch  in  thickness.  Before  my  case  hap- 
pened, Herard  in  1847  and  Bontemps  in  1882*  had  reported 
similar  ones,  without  drawing  any  medico-legal  conclusions 
from  them. 

Dr.  Grawitz,  a  German  physician,  made  some  researches 
on  this  subject  in  1888.  He  noticed  that  all  the  children  in 
whom  an  abnormally  enlarged  thymus  was  {ound  post-mortem 
died  in  the  same  manner  ;  they  w^ere  in  good  health,  when, 
while  sucking  or  drinking  out  of  a  cup  or  a  spoon,  they 
threw  back  their  heads  and  died  without  a  cr}'  or  convulsion, 
or  even  any  movement  at  all. 

Some  weeks  ago  M.  Marfan  found  a  thymus  weighing  over 
an  ounce,  and  measuring  3^  inches  in  length,  i^  inches  in 
breadth,  and  f  inch  in  thickness,  in  an  infant.  The  dimen- 
sions in  this  case  are  almost  the  same  as  in  that  which 
I  met  with  myself,  and  which  I  have  just  mentioned  to  you. 

Dr.  Grawitz  does  not  think  that  death  is  due  to  pressure 
on  the  trachea  and  bronchi ;  he  bases  his  belief  on  the  fact 
that  the  calibre  of  the  air-passages  w^as  not  reduced  in  any 
of  his  autopsies.  This  agrees  with  my  own  observations  ;  I 
have  never  found  the  trachea  distorted.  But  the  trachea 
and  bronchi  are  very  elastic  in  children,  and  resume  their 
natural  form  directly  the  sternum  is  removed.  No  cor- 
clusion  can  therefore  be  drawn  from  this  fact.  For  my  part, 
I  believe,  as  does  M.  Marfan  also,  that  the  thymus  does 
compress  the  trachea ;  this  compression  gives  rise  to  a 
slight  degree  of  spasm,  which  rapidly  causes  the  child's 
death. 

Subpleural  ecchymoses  and  ecchymoses  on  the  thymus  are 
found  in  these  cases.  You  see  at  once  how  necessary  it  is, 
in  presence  of  these  phenomena,  always  to  examine  the 
thymus  in  a  child  who  has  died  suddenly,  in  order  that  no 
suspicion  of  crime  may  fall  upon  an  innocent  person. 

Polypi  of  the  trachea  also  give  rise  to  analogous  spasms. 

Whooping-cough  has  not  a  very  bad  reputation,  generally 
speaking,  among  the  public  ;  however,  it  may  end  fatally  by 

*  Bontemps,  'De  la  Mort  subite  chez  les  jeunes  Enfants.'  Th^se , 
Paris,  1882. 


268  SUDDEN  DEATH 


broncho-pneumonia,  or  by  laryngeal  spasm.  M.  Ducastel* 
collected,  in  1872,  10  cases  of  sudden  death  in  whooping- 
cough  in  children  under  the  age  of  4  years. 

Lastly,  fragments  of  food  may  enter  the  trachea  and 
bronchi ;  it  is  always  necessary  to  see  whether  these  tubes 
are  clear  in  making  medico-legal  autopsies.  Parrot  has 
reported  several  cases  of  the  kind.  It  happens  nearly 
always  in  a  child  lying  on  its  back  and  suffering  from  indi- 
gestion, so  that  food  regurgitates  into  the  respiratory  passages. 

M.  Miqueljf  of  Amboise,  relates  a  curious  instance  of  this 
accident : 

It  happened  in  a  child  20  months  old,  whose  father  had 
just  returned  from  work,  and  gone  to  bed.  The  child,  which 
was  on  its  nurse's  lap,  began  to  cry.  The  father  was  out  of 
temper,  and  went  towards  the  child  and  said  :  '  Will  you 
not  be  quiet,  then,  you  ugly  little  monkey !'  The  child 
became  silent,  drew  a  deep  breath,  and  died  immediately. 
The  child  was  strong,  and  had  been  healthy  hitherto.  It 
had  eaten  nothing  that  morning,  though  it  had  just  been 
drinking  some  sugar-and-water.  Its  death  was  put  down 
to  emotion,  to  the  fear  which  the  father's  exclamation 
had  aroused.  This  was  evidently  the  starting-point  of  the 
untoward  event. 

Post-mortem. — The  trachea  was  found  full  of  food,  sticky 
yellowish  liquid  similar  to  the  contents  of  the  stomach. 
The  child  had  had  a  regurgitation  as  a  result  of  emotion,  and 
died  because  the  trachea  was  obstructed  by  fragments  of  food. 

D.  PULMONARY  CONGESTION. 

x\nother  common  cause  of  sudden  death,  in  children  5  or 
6  months  old,  is  bronchitis.  The  following  example  shows 
how  suspicion  may  arise  in  such  cases : 

A  child  is  found  dead  in  its  cradle  one  morning,  and  its 
nurse  and  mother,  especially  if  the  mother  is  an  unmarried  girl, 
are  accused  of  having  smothered  the  child  by  pressure  with 
the  arm.     An  autopsy  is  ordered,  and  this  is  what  is  usually 

*  Ducastel,  '  De  la  Mort  par  Acces  de  Suffocation  dans  la  Coqueluche.' 
Paris,  1872. 

t  Dr.  Miquel,  d'Amboise,  Gaz.  des  Hop..,  1848. 


IN  CHILDREN.  269 


found: — You  know  that,  in  what  is  called 'capillar)^  bronchitis' 
or  'suffocating  catarrh  of  children'  (Laennec),  intense  pul- 
monary congestion  now  and  then  occurs,  which  places  the 
child's  life  in  jeopardy  for  several  hours.  When  the  child 
is  strong,  and  is  more  than  7  or  8  months  old,  it  seldom 
dies  of  the  first  attack  of  congestion.  But  when  the  age  is 
less  than  6  months,  death  may  occur  in  the  first  attack,  and 
at  the  autopsy  Tardieu's*  subpleural  spots  and  froth  in  the 
bronchi  are  found.  On  examining  the  lungs,  some  portions 
of  the  tissue  are  felt  by  the  finger  to  be  rather  hard,  though 
they  float  in  water.  When  you  have  to  deal  with  such  a 
case,  squeeze  these  portions  of  the  lung  between  your 
fingerSj  and  you  will  make  little  rods  of  muco-pus  emerge 
from  the  divided  ends  of  the  bronchial  ramifications. 

This  experiment  is  the  only  one  which  will  enable  you  to 
recognize  positivel}"  the  existence  of  bronchitis  in  the  new- 
born or  very  young  infant  :  it  ought  always  to  be  practised 
when  any  one  is  accused  of  murdering  a  child  ;  it  may  help 
you  to  exonerate  an  innocent  person. 

Bronchitis  is  one  of  the  most  dangerous  diseases  to  which 
children  are  liable  :  the  child  cannot  cough  ;  it  does  not 
know  how  to  expectorate,  or  how  to  free  itself  from  the 
obstruction  to  its  breathing  ;  part  of  the  respiratory  area 
thus  becomes  useless,  and  the  lesions  just  described,  of 
atelectasic  portions  of  the  lungs,  are  found  post-mortem : 
it  is  Laennec's  '  suffocating  catarrh.' 

Pulmonary  congestion  is  an  accident  which  may  complicate 
any  sort  of  fever  :  it  is  a  serious  condition,  but  it  is  rare  for 
pulmonary  congestion  to  give  rise  to  rapid  and  suspicious 
death  under  these  circumstances. 

Pulmonary  tuberculosis  has  been  the  cause  of  many  medico- 
legal autopsies  that  have  been  made  at  the  Morgue  :  the 
presence  of  tubercle  had  been  absolutely  unsuspected,  and 
yet  the  little  patients  had  sometimes  been  in  our  hospitals 
under  the  care  of  our  most  eminent  physicians.  These 
cases,  it  is  true,  mostly  happened  some  time  ago,  when 
nothing  was  known  of  micro-biology,  and  no  one  dreamt 
of  looking  for  Koch's  bacillus,  the  existence  of  which  was 

*  Tardieu,  'Etude  medico-Iegale  sur  I'lnfanticide.'     2"  Edition,  1880. 


270  SUDDEN  DEATH 


unknown ;  it   is  plain  that  such  things   cannot  happen  so 
frequently  nowadays. 

M.  Vibert  has  three  times  made  an  autopsy  on  children 
under  one  year  of  age  who  have  died  of  typhoid  fever  ;  these 
cases  have  been  published.  In  none  of  them  was  the  child 
suspected  to  be  suffering  from  typhoid  fever  ;  none  of  them 
had  been  seen  by  a  medical  man.  When  interrogated,  the 
mothers  or  nurses  all  replied  that  the  children  had  not  taken 
the  breast  well  for  some  days ;  but  they  all  declared  that 
there  had  been  no  fever,  and  nursing-women  know  very 
well  whether  the  child  has  fever  or  not  by  the  heat  of 
its  mouth.  Post-mortem :  M.  Vibert  found  hypertrophy  of 
Peyer's  patches,  which  is  an  indication  of  typhoid  fever,  but 
the  immediate  cause  of  death  in  each  case  was  pulmonary 
congestion. 

E.  INTESTINAL  DISORDERS. 

The  disorders  of  the  alimentary  canal  which  may  give  rise 
to  sudden  and  suspicious  death  are  cholera  infantum,  which 
is  sometimes  attributed  to  poisoning,  anc  is  generally  due 
to  bad  feeding  ;  and  intestinal  hmnorrhage.  Intestinal 
hsemorrhage  has  been  supposed  to  happen  in  tuberculous 
children,  but  Bouchut  long  ago  called  attention  to  the 
frequency  of  these  haemorrhages  in  children  where  it  is 
impossible  to  assign  any  definite  cause  for  them. 

I  repeat,  in  conclusion,  that  the  three  affections  which 
dominate  the  pathogeny  of  sudden  death  in  children  are 
convulsions,  spasms  of  the  larynx,  and  pulmonary  conges- 
tion. 


THE    END. 


Bailliere,  Thidall  6r=  Cox,  20  and  21,  King  William  Street,  Strand. 


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